Abstract
BACKGROUND: Minimally invasive liver surgery has rapidly evolved in recent years. In addition to the laparoscopic liver resection (LLR), robot-assisted liver resection (RLR) is increasingly gaining in importance; however, although the robotic-assisted approach offers clinical benefits, particularly in complex procedures, it remains a matter of debate. OBJECTIVE: The aim of this study was to present the development, perioperative outcomes, key challenges, and insights from over 500 minimally invasive liver resections performed at a specialized high-volume center. It focused on the comparison between LLR and RLR based on the IWATE difficulty score. MATERIAL AND METHODS: A retrospective single-center analysis of 526 consecutive elective minimally invasive liver resections (2018-2024) was conducted. All cases were stratified using the IWATE score. The LLR and RLR were compared in terms of operative parameters, conversion rate and postoperative complications. Additionally, the annual procedural development was analyzed. RESULTS: The RLR was established in 2021 and accounted for over 50% of all minimally invasive liver resections by 2024. Compared to LLR, RLR was associated with significantly reduced intraoperative blood loss as well as lower conversion and complication rates, particularly in technically demanding resections. Despite an increasing proportion of advanced/expert resections, the rate of major complications could be reduced over time. CONCLUSION: Minimally invasive liver resections can be safely performed at high-volume centers. The robotic-assisted technique offers specific advantages especially in complex resections, with respect to complication rates, reduced conversion rates and decreased blood loss. A key success factor in the implementation of robotic liver surgery is the pre-existing expertise in laparoscopic techniques, which significantly shortened the learning curve. The use of standardized techniques such as the scissor hepatectomy may have contributed to the comparatively low rate of bile leaks observed in RLR.