Safety of Minimally Invasive Laparoscopic Approach in Major Liver Surgery

Due to inherent peculiarities and difficulties of liver surgery, the minimally invasive approach has spread in this field at a slower pace compared to other surgical specialties. The laparoscopic approach in liver surgery has been associated with an improved postoperative course, including reduced morbidity, intraoperative blood losses, length of hospitalization, and unaltered oncological outcomes. The current consensus guidelines, although mainly based on non-randomized studies, recognize that in expert hands, laparoscopic major hemi-hepatectomies are associated with reduced hospital stay and blood loss, while oncological outcomes are comparable to those of an open approach. Given these advantages, the development of a laparoscopic liver resection program is recommended in every hepatobiliary center. The use of the robotic platform in liver surgery carries some potential advantages. An enhanced surgical view with a stable camera, tremor filtration, and wristed instruments bring potential advantages to liver surgery by facilitating the dissection of the hepatoduodenal ligament, the hepatocaval confluence and identification and ligation of the structures encountered during parenchymal transection. Liver mobilization is also facilitated by the stable retraction ensured by the fourth robotic arm. To date, non-randomized studies have shown that robotic-assisted liver surgery achieves results comparable to laparoscopy, although the cost-benefit ratio is still unfavorable. However, the robotic platform seems to shorter the learning curve and ease the adoption of minimally invasive techniques by open surgeons.