**11. Conclusions**

*Liver Disease and Surgery*

system.

**9.1 Results from robot liver resection**

the types and frequency of robotic hepatectomy.

tions reported in the literature since 2013.

other has reported major complications only.

**10. The future of robotic liver surgery**

surgery has been shown worldwide.

Due to the less complex nature of surgery the most common robotic liver procedures performed globally are minor hepatectomy; segmentectomies (29%), left lateral sectionectomies (13%) and bisegmentectomies (9%). **Table 3** demonstrates

This table illustrates the frequencies of the different types of robotic liver resec-

A recent meta-analysis published in 2013 has summarised the results of robotic liver resection up to 2013 [30]. The reader is directed here for the early results of robotic liver resection. In summary the number of major hepatectomies reported in the literature increased as experience with robotic surgery improved. The overall data suggested that robotic assisted liver surgery was comparable to both open and laparoscopic surgery in terms of peri-operative and postoperative outcomes, as well as oncologic efficacy. Complex procedures, such as extended liver resections were suggested to be technically easier due to the intrinsic advantages of the robotic

We discuss the results of robotic liver resection from 2013 to the current period. A number of selected studies reporting outcomes for robotic liver surgery since 2014 are shown in **Table 4**. This list is an exhaustive but highlights the progress that has been made worldwide in advancing robotic liver surgery. Achieving complete resection margins in liver surgery is critical for disease- and recurrence-free survival. It is currently still under investigation if minimal invasive techniques with reduced haptic feedback result in the same oncological results as open surgery. Unfortunately some studies still do not report complete resection rates (termed R0) in their data. However reviewing studies from 2014 onwards most report R0 resection rates of over 90% with many reporting 100%. The long-term outcome although is not well reported and many of these studies have not had the necessary follow-up time for this to be reported and this data is eagerly awaited. The limited studies that have been published appear to report equivalent disease-free and overall survival reported for HCC patients undergoing robotic-assisted versus laparoscopic liver surgery [37]. Although as discussed above robotic liver surgery carry increased costs the reported blood loss is in line with open and laparoscopic surgery and there is reassuringly low open conversion rate that is equivalent to laparoscopic surgery. As the experience with robotic surgery has increased more recent studies have shown that the rate of major hepatectomy completed robotically has increased with low mortality. The morbidity however needs to be carefully interpreted as many studies report overall complications, that include minor complications, whereas as

The robotic platform has distinct advantages over open and laparoscopic surgery and in some instances overcomes the limitations associated with these approaches. In particular the 3-D view, improved images and increased dexterity of operating improve the operators ability to carry out surgery without compromising patient safety. As demonstrated in this chapter the safety and feasibility of robotic liver

The future in robot liver surgery may lie in using this platform to perform more complex liver surgery such as extended liver resections or by incorporating digital technology into the operating system but most importantly the for the field to keep evolving there is a real need for randomised clinical trials. This will allow definition

**232**

The current data suggest that both major and minor robotic hepatectomy is a safe and effective procedure with equivalent patient outcomes in terms of morbidity and mortality and oncological resection. There remain some important limitations to the wider dissemination of this technology principally around cost, some around training and so with the platform itself. It is hoped that collaborations between industry, academia and surgeons will overcome these problems allowing robotic liver surgery to be practiced widely and deliver patient benefit.
