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Review  |  Open Access  |  11 Oct 2020

Robotic vs. laparoscopic major hepatectomy

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Ioannis A. Ziogas1
, 
Samer Tohme2
, 
David A. Geller2
Mini-invasive Surg 2020;4:69.
10.20517/2574-1225.2020.63 |  © The Author(s) 2020.
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Abstract

The introduction of laparoscopic technology and surgical robots in hepatobiliary surgery in the 1990s and 2000s, respectively, has dramatically revolutionized the field. Even though laparoscopic and robotic major hepatectomy was slower to adopt compared to minimally-invasive minor hepatectomy, the number of major hepatectomies performed with both approaches worldwide has significantly increased and is still rising. Despite the few comparative studies between laparoscopic and robotic major hepatectomy, most studies are focused on describing the procedures or reporting the outcomes of each method, either separately, or mixed with minor hepatectomies. Based on the available data, the direct comparison between the two techniques has shown that when robotic major hepatectomy is performed by experienced hepatobiliary surgeons in high-volume centers, it can lead to similar operating times, estimated blood loss, hospital length of stay, complication and mortality rates compared to its laparoscopic counterpart. The likelihood of achieving a margin-negative resection in cancer patients, as well as long-term disease-free and overall-survival are comparable between the groups. However, broader adoption of the robotic approach might be a hurdle in low-volume centers due to the high fixed capital and annual maintenance cost of the surgical robot.

Keywords

Hepatectomy, liver resection, major hepatectomy, laparoscopic, robotic, minimally-invasive
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Introduction

The introduction of minimally-invasive technology in the approach of liver disorders in the early 1990s has since revolutionized the field of liver surgery[1-5]. Laparoscopic liver surgery does not only include pure laparoscopy, but also hand-assisted laparoscopic, as well as hybrid approaches, where the initial part of the procedure (i.e., liver mobilization, early dissection) is done laparoscopically, while later a small incision is made to complete the transection of the liver parenchyma[6,7]. The liver is classified in individual territories according to the segmentation of the vessels and bile ducts, introduced by Couinaud in the 1950s[8,9], and the Brisbane 2000 nomenclature is utilized to define minor and major hepatectomy in the field of liver surgery[10,11]. Minor hepatectomy is defined as the resection of two or fewer Couinaud segments, while major hepatectomy is the removal of three or more Couinaud segments[11]. The first series on laparoscopic liver resections consisted mostly of minor liver resections[3,4,12,13]. The first laparoscopic major hepatectomy (LMH) was performed in 1997[14]. The higher risk for uncontrolled hemorrhage and the requirement of advanced technical expertise, particularly related to major vessel dissection, have slowed the broader adoption of minimally-invasive approaches for major hepatectomy[15].

The technological advances of our era have also led to the broader implementation of robotics in several fields of surgery, including liver surgery. The ability to obtain three-dimensional and magnified intraoperative vision, the significant decrease in hand tremor, as well as the benefit for the surgeon of operating under more relaxed and comfortable circumstances, have led to a considerable growth in robotic surgery, which can overcome the rigid instrumentation and the limited two-dimensional vision associated with laparoscopic surgery[16,17]. These characteristics, along with the advent of wristed instruments, can lead to improved dexterity and higher precision in surgical dissection; this is of particular benefit to liver resection, as hilar dissection, curved transection of the liver parenchyma and the resection of lesions in the posterosuperior segments can be more feasible with the use of a robot[18]. The first large series of robotic liver resection was reported in 2002[19], and although most current experience is based on minor resections, several studies have reported robotic major hepatectomy (RMH). This review aims to summarize the current state of evidence about the outcomes after LMH vs. RMH. We acknowledge that there is still a very important role for open hepatectomy in cases of multiple bilobar liver tumors or large tumors near critical vascular structures. However, we will focus on the differences between LMH and RMH, as a full review of open major hepatectomy is beyond the scope of this review.

International consensus and learning curves

Before engaging in a head-to-head comparison between LMH and RMH, it is worth mentioning two points that may favor the former approach. First, LMH has been performed for many more years than its robotic counterpart; second, irrespective of the procedural, hospitalization, and total economic cost, the cost of purchasing a robot for a hospital is considerable and has been a major limiting factor to the broader adoption of robotic liver surgery. These two points are of paramount importance, as data suggest that outcomes improve as experience with a surgical approach grows[20]. It is also worth mentioning that during the second international consensus on laparoscopic liver surgery (Morioka 2014), the jury concluded that laparoscopic minor hepatectomy had at that point already become standard practice, while LMH was still considered to be an innovative procedure still under exploration[11]. According to the 2018 international consensus statement on robotic hepatectomy, RMH was deemed to be as safe and feasible as both LMH and open major hepatectomy[21].

For the purpose of this review, we performed a non-systematic search of the PubMed bibliographic database using combinations of the following terms: “laparoscopic”, “robotic”, “minimally invasive”, “hepatectomy”, “major hepatectomy”, “liver resection”, and “major liver resection” (last search March 2020). We included comparative or non-comparative studies reporting on the number of LMH and RMH cases. Tables 1, 2, and 3 present the previously published cases of RMH and LMH[6,7,12-14,20,22-109], and it is apparent that the experience with LMH is greater than that of the robotic approach.

Table 1

Previously published reports on robotic major hepatectomy

AuthorCountry/regionStudy periodTotal number of robotic casesRobotic major hepatectomy
Total majorLeft hepatectomyRight hepatectomy
Giulianotti et al.[72] 2011  Italy & USAMar 2002-Mar 2009                  70        27            5            20
Ji et al.[83] 2011  ChinaApr 2009-Jul 2009                  13        9            6            2
Tsung et al.[20] 2014  USANov 2007-Dec 2011                  57        21            n/a            n/a
Spampinato et al.[94] 2014  ItalyJan 2009-Dec 2012                  25        25            7            16
Yu et al.[105] 2014  South KoreaMay 2010-Oct 2011                  13        3            3            0
Wu et al.[22] 2014  TaiwanJan 2012-Dec 2012                  52        14            0            0
Felli et al.[23] 2015  ItalyApr 2013-May 2014                  20        2            2            0
Lee et al.[24] 2016  ChinaSep 2010-Jan 2015                  70        14            10            4
Kingham et al.[25] 2016  USA2010-2014                  64        6            4            2
Lai et al.[26] 2016  ChinaMay 2009-Feb 2015                  100        27            6            20
Lee et al.[27] 2016  ChinaSep 2010-Apr 2015                  15        5            3            2
Sham et al.[28] 2016  USAMay 2011-Dec 2014                  71        17            n/a            n/a
Chen et al.[29] 2016  TaiwanMay 2013-Aug 2015                  13        13            0            13
Chen et al.[30,31] 2017  TaiwanJan 2012-Oct 2015                  183        92            32            41
Quijano et al.[32] 2017  SpainOct 2010-Apr 2016                  21        5            2            1
Magistri et al.[33] 2017  ItalyJan 2012-May 2016                  22        2            0            2
Efanov et al.[34] 2017  RussiaMay 2010-Jun 2016                  40        2            2            0
Daskalaki et al.[35] 2017  USAJan 2009-Dec 2013                  68        29            2            21
Choi et al.[36] 2017  South KoreaDec 2008-May 2016                  70        54            27            12
Khan et al.[37] 2018  International2006-2016                  61        16            8            8
Goja et al.[38] 2019  IndiaFeb 2015-Jan 2016                  21        6            3            3
Lim et al.[39] 2019*  France2011-2017                  61(55)        9(4)            n/a            n/a
Marino et al.[40] 2019  ItalyApr 2016-Mar 2017                  14        14            0            14
Marino et al.[41] 2019  ItalyApr 2015-May 2017                  35        35            35            0
Fruscione et al.[42] 2019  USA2011-2016                  57        57            20            20
Gravetz et al.[43] 2019  USA2013-2017                  33        8            n/a            n/a
Magistri et al.[44] 2019  ItalyJul 2014-Sep 2017                  60        3            1            2
Lee et al.[45] 2019  South KoreaJun 2016-Apr 2018                  13        8            8            0
Mejia et al.[46] 2020  USAAug 2013-Sep 2018                  43        8            4            4
Sucandy et al.[47] 2020  USA2013-2018                  80        24            14            6
Beard et al.[48] 2020*  InternationalJan 2008-Oct 2016                  115        17            6            9

*Numbers in parentheses represent the number of cases after propensity score-matching. n/a: not available

Table 2

Previously published reports on laparoscopic major hepatectomy

AuthorCountry/regionStudy periodTotal number of laparoscopic casesLaparoscopic major hepatectomy
Total majorLeft hepatectomyRight hepatectomy
Huscher et al.[14] 1997  Italy1993-Dec 1995                      20      14            6            5
Gigot et al.[49] 2002  EuropeFeb 1994-Dec 2000                      37      2            n/a            n/a
O’Rourke et al.[6] 2004  AustraliaNov 1999-Sep 2002                      12      12            0            12
Dulucq et al.[50] 2005  FranceJan 1995-Jan 2004                      32      11            4            6
Vibert et al.[51] 2006  FranceJan 1995-Dec 2004                      89      38            3            27
Topal et al.[52] 2007  Belgiumn/a                      2      2            0            2
Gayet et al.[53] 2007  Francen/a                      41      41            0            37
Koffron et al.[12] 2007  USAJul 2001-Nov 2006                      300      119            47            64
Dagher et al.[54] 2007  FranceFeb 1999-Jan 2006                      70      19            5            12
Gumbs et al.[55] 2008  Francen/a                      3      3            0            0
Gumbs et al.[56] 2008  Francen/a                      5      5            0            0
Cho et al.[57] 2008  South KoreaJan 2004-Dec 2007                      128      47            23            13
Buell et al.[13] 2008  USAJan 2001-Apr 2008                      253      69            24            33
Topal et al.[58] 2008  BelgiumOct 2002-Jun 2007                      109      21            4            14
Dagher et al.[59] 2008  FranceSince Feb 1999                      20      20            0            20
Wakabayashi et al.[60] 2009  JapanJul 1995-Apr 2008                      176      39            10            12
Castaing et al.[61] 2009  FranceJan 1997-May 2007                      60      26            0            22
Nguyen et al.[62] 2009  USA & EuropeFeb 2000-Sep 2008                      109      49            10            31
Vigano et al.[63] 2009  FranceJan 1996-Aug 2008                      174      35            n/a            23
Bryant et al.[64] 2009  FranceMay 1996-Dec 2007                      166      31            11            19
Yoon et al.[65] 2009  South KoreaOct 1998-Jun 2007                      46      21            21            0
Cho et al.[66] 2009  South KoreaMay 2003-Apr 2007                      40      12            0            5
Baker et al.[67] 2009  USAJan 2006-May 2008                      33      33            0            33
Dagher et al.[68] 2009  International1997-2008                      210      210            74            136
Cai et al.[69] 2009  China2005-2007                      19      19            19            0
Dagher et al.[70] 2009  FranceFeb 2002-Aug 2007                      22      22            0            22
Yoon et al.[71] 2010  South KoreaSep 2003-Nov 2008                      69      21            2            6
Nitta et al.[7] 2010  JapanNov 2002-Dec 2008                      42      42            16            14
Dagher et al.[73] 2010  Europe1998-2008                      163      16            4            10
Martin et al.[74] 2010  USAJan 2000-Jun 2009                      90      90            50            40
Ji et al.[83] 2011  ChinaApr 2009-Jul 2009                      20      4            3            1
Shafaee et al.[75] 2011  USA & Europe1997-2009                      68      22            1            12
Cho et al.[76] 2011  JapanAug 2005-Feb 2010                      27      20            5            10
Abu Hilal et al.[77] 2011  UK2006-2009                      36      36            0            36
Bhojani et al.[78] 2012  CanadaJun 2006-May 2010                      57      19            5            8
Topal et al.[79] 2012  BelgiumOct 2002-Dec 2008                      20      20            4            13
Cannon et al.[80] 2012  USA2004-2010                      35      19            4            14
Gumbs et al.[81] 2012  USANov 2008-Oct 2010                      53      25            8            13
Abu Hilal et al.[82] 2013  UKMar 2006-Nov 2011                      84      38            0            38
Tsung et al.[20] 2014*  USANov 2007-Dec 2011                      114      42            n/a            n/a
Spampinato et al.[94] 2014  ItalyJan 2009-Dec 2012                      25      25            8            15
Yu et al.[105] 2014  South KoreaJul 2007-Oct 2011                      17      11            11            0
Wu et al.[22] 2014  TaiwanJan 2012-Dec 2012                      69      4            0            0
Medbery et al.[84] 2014  USAMay 2008-Mar 2012                      48      48            0            48
Zhang et al.[85] 2014  ChinaJuly 2011-Mar 2013                      25      25            0            25
Ahn et al.[86] 2014  South KoreaJan 2005-Feb 2013                      51      2            2            0
Benkabbou et al.[87] 2015  MoroccoJun 2010-Feb 2013                      13      2            1            1
Xiao et al.[88] 2015  ChinaJan 2010-Dec 2012                      41      4            0            0
Takahara et al.[89] 2015*  Japan2000-2010                      436(387)      46(42)            n/a            n/a
Allard et al.[90] 2015  FranceJan 2006-Dec 2013                      176      80            14            63
Beppu et al.[91] 2015*  JapanJan 2005-Dec 2010                      210(171)      12(10)            n/a            n/a
de’Angelis et al.[92] 2015  FranceJan 2000-Dec 2013                      52      18            2            15
van der Poel et al.[93] 2016  UKAug 2003-Mar 2015                      159      159            54            105
Lee et al.[24] 2016  ChinaNov 2003-Jan 2015                      66      2            2            0
Lai et al.[26] 2016  ChinaOct 1998-Feb 2015                      35      1            0            1
Takahara et al.[95] 2016  JapanJan 2011-Dec 2013                      929      929            238            234
Cipriani et al.[96] 2016  UKAug 2004-Apr 2015                      133      65            8            43
Ratti et al.[97] 2016  Italy2008-2014                      25      6            4            2
Tranchart et al.[98] 2016  International1997-2013                      89      7            3            4
Untereiner et al.[99] 2016  FranceJan 2012-Jan 2015                      18      2            2            0
Komatsu et al.[100] 2016  FranceJan 2006-May 2014                      38      38            10            28
Martinez-Cecilia et al.[101] 2017*  EuropeJan 2005-Dec 2012                      287(225)      49(47)            n/a            n/a
Sotiropoulos et al.[102] 2017  GreeceJan 2012-Jan 2017                      42      1            1            0
Peng et al.[103] 2017  ChinaJan 2013-Oct 2016                      36      15            15            0
Chen et al.[104] 2017  ChinaApr 2015-Sep 2016                      225      126            26            43
Efanov et al.[34] 2017  RussiaMay 2010-Jun 2016                      91      11            2            9
Lim et al.[39] 2019*  France2011-2017                      111(55)      15(8)            n/a            n/a
Marino et al.[40] 2019  ItalyApr 2016-Mar 2017                      20      20            0            20
Fruscione et al.[42] 2019  USA2011-2016                      116      116            22            46
Jang et al.[106] 2019  South KoreaJan 2014-Jul 2017                      37      17            9            8
Cipriani et al.[107] 2019  ItalyJan 2005-Nov 2017                      145      145            59            86
Chen et al.[108] 2019  TaiwanDec 2010-Dec 2016                      436      90            31            52
Lee et al.[45] 2019  South KoreaJun 2016-Apr 2018                      10      3            3            0
Mejia et al.[46] 2020  USAJun 2005-Sep 2018                      171      46            13            33
Cipriani et al.[109] 2020  EuropeJan 2007-Feb 2016                      597(545)      597(545)            215(172)            382(351)
Beard et al.[48] 2020*  InternationalJul 2002-Oct 2017                      514(115)      53(21)            17 (n/a)            33 (n/a)

*Numbers in parentheses represent the number of cases after propensity score-matching. n/a: not available

Table 3

Previously published reports on the comparison of laparoscopic and robotic liver resection along with the number of major hepatectomy cases in each group

AuthorTotal laparoscopicLaparoscopic major hepatectomyTotal roboticRobotic major hepatectomy
Ji et al.[83] 2011        20                      4      13                    9
Tsung et al.[20] 2014        114                      42      57                    21
Spampinato et al.[94] 2014        25                      25      25                    25
Yu et al.[105] 2014        17                      11      13                    3
Wu et al.[22] 2014        69                      4      52                    14
Lee et al.[24] 2016        66                      2      70                    14
Lai et al.[26] 2016        35                      1      100                    27
Efanov et al.[34] 2017        91                      11      40                    2
Lim et al.[39] 2019*        111(55)                      15(8)      61(55)                    9(4)
Marino et al.[40] 2019        20                      20      14                    14
Fruscione et al.[42] 2019        116                      116      57                    57
Lee et al.[45] 2019        10                      3      13                    8
Mejia et al.[46] 2020        171                      46      43                    8
Beard et al.[48] 2020*        514(115)                      53(21)      115                    18

*Numbers in parentheses represent the number of cases after propensity score-matching

Determining the learning curve for each approach is also of major significance. The learning curve is “the improvement in performance over time or the change in the ability to complete a task until failure is decreased to a constant acceptable rate”[110]. Data suggest that the learning curve for LMH is around 45-60 cases[93,111-113]. van der Poel et al.[93] reported that 55 is the “golden” number for LMH; however, all surgical operations were performed by two experienced hepatobiliary surgeons with at least three years of additional experience on minor laparoscopic hepatectomy. For RMH, Chen et al.[30] described an initial phase of 15 patients followed by an intermediate phase of 25 patients. The accumulated experience of the first 15 cases (defined as the “initial learning curve”), mostly comprised of right and left hemihepatectomies, was followed by more complex cases, such as trisectionectomy and 8-5-4 trisegmentectomy, in the next 25 cases (“phase of increased competency”). Their last 52-case “matured phase” was associated with an overall improvement in outcomes. However, the authors did not mention who their “learning curve” refers to, as “all procedures were performed by the same operative team”, but they do not specify their prior experience with minor robotic resections or even with LMH. Tsung et al.[20] reported that the outcomes of their robotic cases between 2010-2011 were superior to those of the robotic cases between 2007-2010, but the authors pooled together both minor and major resections for this comparison.

Operating time

A systematic review and pooled analysis of outcomes on robotic liver resections showed that the mean operating time for RMH (≥ 4 segments) was 405 ± 100 min[18], while another more recent systematic review reported similar pooled mean operating rime for RMH (≥ 3 segments) of 403.4 ± 107.5 min[114]. A systematic literature review on LMH[115] showed that mean operating time in all individuals studies was lower than the pooled operating times reported in the RMH systematic reviews[18,114]. Additionally, in a systematic review comparing LMH to open major hepatectomy, the pooled mean operating time in the LMH arm was 285 ± 105.6 min[116]. Similarly, in a large multicenter study from Europe, Cipriani et al.[109] reported a median operating time of 300 min (IQR 205-380) for LMH, and more specifically 300 min (IQR 240-402) for right hepatectomy and 270 min (IQR 160-290) for left hepatectomy. Tsung et al.[20] compared RMH vs. LMH, and showed that both overall operating room time (452 min vs. 348.5 min) and operating time (330 min vs. 280.5 min) were significantly longer in the RMH group. Spampinato et al.[94] also showed that operating time was longer in RMH (430, IQR 240-725 min) when compared to LMH (360, IQR 180-600 min), while all procedures were performed by surgeons experienced in minimally-invasive liver surgery. Notably, a more recent study showed no difference in median operating time between RMH (194, range 152-255 min) and LMH (204, 149-280 min), and all of the operations were again performed by experienced minimally-invasive hepatobiliary surgeons[42]. A Korean group recently published the initial experience of a single surgeon with robotic liver surgery and showed that there was no difference in operating time between robotic and laparoscopic left hepatectomy (248.6 ± 37.5 min vs. 226.7 ± 26.6 min)[45]. Another recent study comparing robotic vs. laparoscopic right hepatectomy demonstrated that operating time was significantly shorter in the robotic group compared to the laparoscopic one (425 ± 139 min vs. 565.18 ± 183.73 min), and all procedures were performed by the same young surgeon[40]. That may serve as an indicator that as experience with RMH grows, operating time seems to decrease and to be equivalent to, or even shorter than, that of LMH. However, a major confounding factor is surgeon’s surgical expertise and prior experience with minimally-invasive major hepatectomy; thus, future studies comparing operating time, as well as other parameters, between RMH and LMH should always mention primary surgeon’s prior experience and should make sure that the two comparison groups are equivalent regarding this parameter.

Estimated blood loss

The pooled estimated blood loss (EBL) in RMH based on two systematic reviews was 543.4 ± 371 mL[114] and 380 ± 505 mL[18], respectively. The pooled mean EBL for the LMH arm in a systematic review comparing LMH to open major hepatectomy was 450.6 ± 563.2[116], which is comparable to the pooled rates reported in the RMH systematic reviews[18,114]. However, major deviations were found between the individual RMH or LMH studies themselves included in each systematic review. Cipriani et al.[109] reported a median EBL of 350 mL (IQR 125-1350) for LMH, and more specifically 400 mL (IQR 200-800) for right hepatectomy and 300 mL (IQR 50-260) for left hepatectomy. Studies directly comparing EBL between RMH and LMH showed that EBL in RMH was lower than that in LMH, while the difference was not statistically significant in any of the individual studies[20,40,42,94].

Length of stay

Two prior systematic reviews on RMH reported a pooled mean hospital length of stay (LOS) of 10.5 ± 4.8[114] and 11 ± 6 days[18], respectively. The mean LOS of most individual studies included in a systematic review on LMH[115] was shorter than that of the two RMH systematic reviews. Another systematic review showed that the pooled mean LOS for LMH was 10 ± 8.7 days[116]. Cipriani et al.[109] reported a median LOS of 6 days (IQR 4-10) for LMH, and more specifically 7 days (IQR 4-13) for right hepatectomy, and 5 days (IQR 4-10) for left hepatectomy. Studies reporting on the direct comparison of RMH vs. LMH did not demonstrate any statistically significant difference between the two arms[20,40,42,94].

Complications, survival and oncologic outcomes

When comparing RMH and LMH, Tsung et al.[20] reported that no difference was observed between the two groups with a complication rate of 24% (n = 5/21) vs. 32% (n = 13/42), respectively, while only one patient in the RMH group experienced a major complication (Clavien-Dindo grade ≥ 3) (4.8% vs. 0%, respectively). The 90-day mortality rate was 0% in both groups[20]. Similar complication rates were documented by Spampinato et al.[94] RMH: 20% (n = 5/25) vs. LMH: 36% (n = 9/25), with 4% (n = 1/25) and 12% (n = 3/25) of the patients experiencing a major complication (Clavien-Dindo grade ≥ 3), respectively. However, one patient in the LMH group died[94]. Marino et al.[40] also failed to show a difference in morbidity with 21.4% (n = 3/14) of the patients in the RMH arm vs. 15% (n = 3/20) in the LMH group experiencing any complications, while no major complications occurred. Ninety-day mortality was 0% in both groups[40]. The largest and most recent comparative study between RMH and LMH was performed by Fruscione et al.[42] and also did not show a significant difference in complications between the two groups. Specifically, the complication rate for RMH was 28.1% (n = 16/57) and for LMH 35.3% (n = 41/116), with 7% (n = 4/57) and 9.5% (n = 11/116) being classified as major complications (Clavien-Dindo grade ≥ 3). No death was reported in either of the comparison arms[42]. Additionally, when RMH and LMH were performed for liver malignancies, none of the four studies showed a difference in surgical margin status between the two approaches (positive margins: 0%-8.3% vs. 7%-15%, respectively), and long-term outcomes were comparable when reported[20,40,42,94].

Economic cost

Mejia et al.[46] reported that the adjusted room and board charges were significantly lower in the LMH vs. the RMH group, with no other difference between the two groups regarding economic cost. Of note, when comparing the cost of LMH vs. RMH, the fixed capital cost ($1,000,000-$2,600,000 for a robotic system with a 10-year longevity period)[117-120] and annual maintenance cost ($90,000-$175,000)[120] for a hospital to purchase and maintain a surgical robot, should also be taken into consideration. The addition of this cost can be burdensome, particularly for low-volume liver surgery centers, and this remains a significant driving factor for the slow spread of RMH and robotic liver surgery in general. It should also be noted that access to the robot in the operating room can be a challenge due to competition with other surgical service lines.

Conclusion

The introduction of laparoscopy and robotic surgical systems in liver surgery has significantly changed the current state of practice. Although both approaches have been more widely tested for minor liver resections, the number of LMHs and RMHs performed worldwide has significantly increased over recent years, and is still on the rise. Although there is a considerable deviation in outcomes after RMH, especially during early experience, when RMH is performed by experienced surgeons in high-volume liver centers, it can be associated with equivalent operating time, EBL, LOS, morbidity and mortality, and comparable oncologic outcomes in terms of achieving a margin-negative resection and long-term overall survival. The fixed capital and annual maintenance costs for the robotic surgical system may pose a significant obstacle in the broader adoption of RMH, particularly in low-volume centers.

Declarations

Authors’ contributions

Study concept, data acquisition, data analysis and interpretation, drafting, critical revision, final approval of the manuscript: Ziogas IA, Tohme S, Geller DA

Availability of data and materials

Not applicable.

Financial support and sponsorship

None.

Conflicts of interest

All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate

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Robotic vs. laparoscopic major hepatectomy
Ioannis A. Ziogas, ... David A. Geller

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Ziogas, I. A.; Tohme S.; Geller D. A. Robotic vs. laparoscopic major hepatectomy. Mini-invasive. Surg. 2020, 4, 69. http://dx.doi.org/10.20517/2574-1225.2020.63

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