Key steps of complex robotic liver surgery: an international expert survey

Background: Robotic liver surgery (RLS) has become the preferred minimally invasive approach for liver surgery. However, especially for complex RLS (C-RLS), key surgical steps such as preoperative preparation, intraoperative techniques, and training are often center-dependent and not standardized. The aim of this survey was to assess the international practice of key surgical steps during C-RLS among expert centers. Methods: A cross-sectional survey was conducted among robotic liver surgeons with a minimum individual experience of 50 RLS to assess their practice during C-RLS. The survey consisted of 50 questions, distributed across three sections: training, preoperative planning, and intraoperative practice for C-RLS. Results: 60 out of 71 experts completed the survey, corresponding to an 85% response rate. 73% of the experts agreed that the IWATE difficulty score represents an adequate classification system to define C-RLS. A prerequisite before performing C-RLS was experience in complex open liver surgery (71%) and expertise in low and intermediate RLS (75%). Mentoring by a more experienced surgeon was deemed necessary by most experts (90%) when performing C-RLS. Vascular inflow control was mentioned to often be performed during parenchyma transection either selectively (38%) or routinely (52%). Most experts considered pre- or intraoperative positive staining helpful (57%), while negative staining (85%) was reported as even more important in C-RLS. For vasculo-biliary transection, experts preferred an intrafascial (45%), glissonian pedicle approach (33%) or a case-dependent transection (12%). For parenchymal transection, the preferred instruments were laparoscopic CUSA (92%), harmonic ACE (78%), and SynchroSeal (77%). Conclusion: This expert survey reveals current international practices for preoperative preparation, training, and intraoperative key steps of C-RLS. Prospective validation of the key steps would be useful for correlating clinical outcomes with current practice.