A commentary on “Feasibility of robotic liver resection compared with laparoscopic and open liver resection for hepatocellular carcinoma: a network meta-analysis”

Dear Editor, Liver cancer is the third largest cause of cancer-related deaths and ranks sixth among the most common malignant tumors around the world, of which hepatocellular carcinoma (HCC) accounts for approximately 75–80% of all cases. Liver resection is still the cornerstone of HCC therapy. There are now three main methods used: robotic liver resection (RLR), open liver resection (OLR), and laparoscopic liver resection (LLR)[1–5]. Due to its minimally invasive nature and excellent safety profile, LLR has been widely applied by hepatobiliary surgeons since it was originally published in 1991. When compared to OLR, LLR is linked to better surgical results in older individuals. RLR has recently been employed more often in clinical practice. In order to evaluate the effect of RLR in comparison to LLR and OLR on short- and long-term outcomes in HCC patients, Kim et al[6] conducted a network meta-analysis. RLR is a viable surgical treatment option for HCC, providing long-term and perioperative results equivalent to LLR, with shorter hospital stays and lower postoperative morbidity than OLR, according to the network meta-analysis that comprised 69 studies. The depth of the liver’s anatomical locations, along with its distinctive and rich vascularization, has made it difficult to perform liver resections using a minimally invasive technique. This has made it difficult to safely replicate the fundamental procedures of open liver surgery laparoscopically. Some of the drawbacks of laparoscopic surgery, which made it less safe than open surgery, appear to be addressed thanks to the robotic technology. Specifically, robotic surgery allows for wrist-worn instruments that improve the suturing and knotting capabilities of laparoscopy, which is very helpful for hemostasis and vascular control, a fourth arm that can act as a stable retractor during all phases of liver resection under the direct control of surgeon, and stable 3D vision that offers outstanding magnification, depth perception, and resolution[7,8]. From an oncological and surgical perspective, this kind of approach is becoming safer due to the employment of more sophisticated technology that is suited to robotic surgery. However, the results could have been impacted by clinical heterogeneity between trials. The survival rate may have been affected by variations in the tumor’s size, stage, degree of hepatectomy, as well as microvascular invasion. Perioperative results may have been impacted by differences in hepatic reserve function, the size of the hepatectomy, and the percentage of liver cirrhosis. Meta-regression analysis and subgroup analyses to further examine these factors were not possible due to the small number of eligible studies. Future multicenter, prospective, large-sample randomized controlled trials will thus be necessary to elucidate the impact of different surgical techniques on the surgical and oncological outcomes of patients with HCC. Furthermore, bias and unmeasured confounding variables were possible because the majority of the included studies were non-randomized controlled trials. Lastly, the results of the study may have been biased due to short follow-up periods in certain cases. In summary, this network meta-analysis indicates that RLR is a feasible option for HCC, showing perioperative and long-term outcomes comparable to LLR and clear advantages over OLR in postoperative morbidity and hospital stay. Nevertheless, the limited number of RLR cases, particularly for long-term outcomes, highlights the need for further studies to confirm its efficacy in HCC. This study adheres to the TITAN Guidelines 2025[9].