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ImportanceLong-term oncologic outcomes of robotic surgery remain a hotly debated topic in surgical oncology, but sparse data have been published thus far.ObjectiveTo 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 ParticipantsThis 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 MeasuresA 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.ResultsThe 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 RelevanceThis 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.

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Treatment of peri-hilar cholangiocarcinoma (PHC) is one of the most critical challenges in the modern era of liver surgery (1). In addition to the highly demanding technique and insidious diagnostic work-up, the procedure is often complicated by potentially life-threatening postoperative sequelae. Therefore, accuracy in the pre-operative indication and planning is paramount to mitigate this risk and to improve the outcomes. The decision to either perform a right or left hepatectomy should be based on several factors, including tumor extension, presence of vascular infiltration, study of the future liver remnant (FLR) and center experience. Franken and colleagues reported their valuable experience with patients affected by PHC (2), comparing 76 left sided liver resections (LH) vs. 102 right sided liver resections (RH) for PHC, to highlight potential advantages of one approach over the other. Authors showed that no statistically significant differences could be found in both short-and long-term outcomes between the two groups. Interestingly, post-hepatectomy liver failure (PHLF) was more frequently observed after RH (22%) compared to LH (11%), almost reaching a significant threshold (P=0.052). Of note, incidence of PHLF seems to be influenced more by the combination of liver and portal vein resection (P=0.005), rather than by the side of the hepatectomy. Despite the efforts to obtain a radical treatment and the risk of severe morbidity, a R0 resection was obtained in only 39% of the cases, without differences between leftand right-sided hepatectomies (40% and 39%, respectively, P=0.849), having considered any margin <1 mm as R1 including all planes.

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