Laparoscopic vs. robotic surgery: What is the data?

© Digestive Medicine Research. All rights reserved. Dig Med Res 2021;4:42 | https://dx.doi.org/10.21037/dmr-21-65 Laparoscopic liver surgery (LLS) is rapidly expanding including laparoscopic major hepatectomy (1), and studies have demonstrated that LLS has several important peri-operative clinical benefits over open hepatectomy including less blood loss, less narcotic requirement, fewer complications, and reduced hospital stay (2,3). Furthermore, three randomized clinical trials have shown that LLS performed for primary or secondary hepatic malignancies does not compromise oncologic outcomes compared again to open hepatectomy (4-6). Robotic liver surgery (RLS) was first reported in 2003 and has since been regarded as the next step in the evolution of minimally-invasive hepatectomy (7). The robotic surgery platforms have several inherent technical features that are appealing to the hepatic surgeon. These features include articulating instruments with more degrees of freedom than conventional laparoscopic instruments, tremor filtering, a surgical endoscope with 3D and magnified view that is controlled by the surgeon and improved comfort and ergonomics for the console surgeon. These combined features lead to less reliance on the assistant surgeon and allow the operating surgeon to perform complex maneuvers such as intracorporeal suturing and vessel dissection with more ease. Theoretical disadvantages of RLS include the lack of haptic feedback, longer operating time due to the required additional steps to “dock” and “undock” the robotic platform and higher costs compared to LLS. Indeed, Tsung et al. in a matched comparison of 57 robotic liver resections with 114 laparoscopic cases, reported similar peri-operative outcomes, but a significantly longer median operative time for RLS (253 vs. 199 minutes) (8). The 2018 International consensus statement on robotic hepatectomy surgery summarizes the recent literature on RLS and concludes that it is a safe and feasible as traditional open hepatectomy, but it is associated with longer operating times, less intraoperative blood loss, shorter length of stay and fewer complications when compared to open liver surgery (7). In terms of minimally-invasive major hepatectomy, both laparoscopic and robotic approaches appear to have equivalent peri-/postoperative outcomes when performed in select patients and high-volume centers according to a recent meta-analysis by Ziogas et al., which included seven studies with a total of 300 laparoscopic and 225 robotic major hepatectomies (9). However, other smaller studies have suggested that RLS is associated with higher intraoperative blood loss and longer operative time compared to LLS (10,11). In terms of long-term oncologic outcomes, a recent propensity-matched analysis of patients who underwent LLS (n=514) or RLS (n=115) for colorectal cancer liver metastasis reported equivalent 5-year overallsurvival (OS) and disease-free survival (DFS) between the two groups (12). Regarding cost, LLS has been shown to be cost-effective compared to open hepatectomy with 17% lower total costs on average (13). When comparing cost between LLS and RLS, several studies have shown higher costs associated with the use of the robotic platform (14). In a large meta-analysis of 38 studies, that included 1,674 patients who underwent LLS and 390 patients with RLS, Ziogas et al. showed higher operating room costs, Editorial