One hundred and fifty-two robotic hepatectomies at a North American hepatobiliary program: Evolution of practice, learning curve, appraisal of outcomes, and cost analysis

Introduction: In North America, the majority of hepatectomies are still performed in traditional open fashion. Robotic hepatectomy may facilitate a minimally invasive approach to liver resection. Objectives: We report a single-center experience with the wide adaptation of robotic hepatectomy over a 5-year period. Materials and methods: Retrospective analysis of a prospectively maintained database of all hepatectomies (n = 334) was performed at our institution from January 2018 to January 2023. This included 164 open, 18 laparoscopic, and 152 robotic hepatectomies. Propensity score matching (PSM) was used to match open (n = 100) to robotic (n = 100) hepatectomy cases by demographics and case complexity. Standard statistics were used to compare 90-day outcomes, including textbook outcome after liver surgery (TOLS), and cost. CUSUM curves were used to determine the learning curve for major hepatectomy. Results: During the study period, laparoscopic hepatectomy was phased out and robotic hepatectomy became the predominant approach. The median IWATE score for the robotic cases was 8 ± 2 and 39% were major hepatectomies. The learning curve for robotic right hepatectomy was 15 cases. When PSM cases were compared, while operative time was longer, blood loss and transfusion, intraoperative incidents, overall and major morbidity, bile leaks, post-hepatectomy liver failure, hypoxia requiring supplemental oxygen, reoperation, ICU utilization, and length of stay were significantly lower in the robotic group. There was no difference in positive margins or 90-day mortality. Robotic hepatectomy was associated with significantly higher TOLS compared to open hepatectomy (85% versus 64%, p < 0.001) and on multivariate analysis, only a robotic hepatectomy approach was independently associated with achieving TOLS (OR 3.3, (1.62–6.67) 95% CI)). The lower ICU utilization and length of stay accounted for a significantly lower overall hospital cost for robotic compared to open hepatectomy despite a higher operating room cost. Conclusion: We describe the successful implementation of robotic hepatectomy at our institution with favorable outcomes and cost.