Safety and Efficacy of Robotic vs Open Liver Resection for Hepatocellular Carcinoma

Abstract

Importance: Long-term oncologic outcomes of robotic surgery remain a hotly debated topic in surgical oncology, but sparse data have been published thus far.

Objective: To analyze short- and long-term outcomes of robotic liver resection (RLR) for hepatocellular carcinoma (HCC) from Western high-volume centers to assess the safety, reproducibility, and oncologic efficacy of this technique.

Design, setting, and participants: This cohort study evaluated the outcomes of patients receiving RLR vs open liver resection (OLR) for HCC between 2010 and 2020 in 5 high-volume centers. After 1:1 propensity score matching, a group of patients who underwent RLR was compared with a validation cohort of OLR patients from a high-volume center that did not perform RLR.

Main outcomes and measures: A retrospective analysis was performed of prospectively maintained databases at 2 European and 2 US institutions of patients who underwent RLR for HCC between January 1, 2010, and September 30, 2020. The main outcomes were safety and feasibility of RLR for HCC and its oncologic outcomes compared with a European OLR validation cohort. A 2-sided P < .05 was considered significant.

Results: The study included 398 patients (RLR group: 125 men, 33 women, median [IQR] age, 66 [58-71] years; OLR group: 315 men, 83 women; median [IQR] age, 70 [64-74] years), and 106 RLR patients were compared with 106 OLR patients after propensity score matching. The RLR patients had a significantly longer operative time (median [IQR], 295 [190-370] minutes vs 200 [165-255] minutes, including docking; P < .001) but a significantly shorter hospital length of stay (median [IQR], 4 [3-6] days vs 10 [7-13] days; P < .001) and a lower number of admissions to the intensive care unit (7 [6.6%] vs 21 [19.8%]; P = .002). Incidence of posthepatectomy liver failure was significantly lower in the RLR group (8 [7.5%] vs 30 [28.3%]; P = .001), with no cases of grade C failure. The 90-day overall survival rate was comparable between the 2 groups (RLR, 99.1% [95% CI, 93.5%-99.9%]; OLR, 97.1% [95% CI, 91.3%-99.1%]), as was the cumulative incidence of death related to tumor recurrence (RLR, 8.8% [95% CI, 3.1%-18.3%]; OLR, 10.2% [95% CI, 4.9%-17.7%]).

Conclusions and relevance: This study represents the largest Western experience to date of full RLR for HCC. Compared with OLR, RLR performed in tertiary centers represents a safe treatment strategy for patients with HCC and those with compromised liver function while achieving oncologic efficacy.

Figure 1.. Hepatocellular Carcinoma (HCC) Identification With Integrated Firefly

Tumor cells can be either hypofluorescent or hyperfluorescent after indocyanine green (ICG) injection according to histologic features. Well-differentiated HCC tumors usually show a homogenous fluorescence pattern, whereas poorly differentiated HCC tumors show an inhomogeneous one or even a rim-type fluorescence pattern.

Figure 2.. Overall Survival and Cumulative Incidence Function (CIF) of Death Related to Tumor Recurrence After Propensity Score Matching by Type of Surgery

Seventeen patients received a liver transplant and were censored on the date of transplant (2 in the open liver resection [OLR] group without recurrence, and 15 in the robotic liver resection [RLR] group [9 without recurrence and 6 with liver transplant after recurrence]). Deaths related to tumor recurrence were considered as events; deaths as a result of other causes were considered as competing events. ^aMedian (IQR) follow-up, 19 (10-33) months. ^bHazard ratio of surgery adjusted for number of nodules, grading, and microvascular invasion.