Letter to the Editor on: “Feasibility of robotic liver resection compared with laparoscopic and open liver resection for hepatocellular carcinoma: a network meta-analysis”

Dear Editor, Hepatocellular carcinoma’s substantial disease burden makes selecting appropriate surgical approaches a key research focus[1]. The network meta-analysis by Sang-Hoon Kim et al in the International Journal of Surgery provides an informative comparison of robotic (RLR), laparoscopic (LLR), and open liver resection (OLR) for hepatocellular carcinoma (HCC), comprehensively assessing these methods and highlighting minimally invasive benefits[2]. The findings suggest that RLR is feasible with outcomes comparable to LLR and advantages over OLR in certain perioperative metrics. However, we would like to raise several points regarding the study’s limitations and implications for future research. First, as the analysis was predominantly based on retrospective matched studies – with only one randomized controlled trial (RCT), three prospective studies, and 65 retrospective-matched studies included out of 69 total studies – the lack of RCTs led us to question the robustness of the conclusions. For instance, retrospective designs often suffer from imbalances in patient characteristics, perioperative management, and follow-up protocols, potentially inflating or underestimating the treatment effects. The absence of high-quality RCTs limits the strength of the evidence, as RCTs are essential for minimizing bias through randomization and blinding. Future studies should prioritize well-designed RCTs with adequate power, standardized protocols, and long-term follow-up to validate these findings and inform clinical decision-making more reliably. Second, significant heterogeneity likely exists across studies due to variations in surgical techniques, patient selection criteria (e.g., tumor size, location, Child-Pugh score), and outcome definitions, potentially impacting outcomes such as blood loss, complications, and survival. This heterogeneity is not adequately addressed in the analysis, potentially compromising result comparability. For example, the included studies exhibited variability in tumor characteristics (e.g., size and number) and cirrhosis status, which could influence outcomes like overall survival and recurrence-free survival. Standardizing selection, approaches, and reporting would enhance reproducibility and generalizability[3]. Additionally, ranking analyses (e.g., RLR superiority) require cautious interpretation owing to potential inconsistencies in outcome measurement and reporting. Third, key clinical outcome reporting remains limited, omitting critical dimensions such as cost-effectiveness, patient-reported outcomes (e.g., quality of life, pain scores), and detailed subgroup analyses (e.g., by tumor stage or surgeon experience). The economic implications of RLR – particularly relevant given its higher upfront costs – are unaddressed despite their importance for resource allocation. For HCC patients, factors such as Child–Pugh class and cirrhosis status are crucial determinants of outcomes and should be integrated into cost-effectiveness and patient-centered evaluations. The absence of these HCC-specific considerations, along with patient-reported outcomes, further constrains holistic technique evaluation[4]. Future studies should integrate comprehensive measures, including cost–benefit analyses and validated patient-reported instruments, for a more rounded assessment of RLR, LLR, and OLR. Fourth, the long-term follow-up data, though reporting no significant differences in 1-, 3-, and 5-year overall survival (OS) and recurrence-free survival (RFS), may be insufficient to draw firm conclusions about oncological efficacy[5]. The follow-up duration in many included studies might be relatively short for HCC, a disease with potential for late recurrence or long-term complications. Besides, the limited RLR sample size reduces statistical power to detect survival differences, particularly beyond 5 years. Extended follow-up and larger cohorts are needed to evaluate RLR’s true long-term benefits/risks, including recurrence patterns and liver function changes over time. In conclusion, this network meta-analysis offers valuable insights into the feasibility of RLR for HCC, but the limitations highlight the need for more rigorous research. Emphasizing high-quality RCTs, reducing heterogeneity through standardization, expanding outcome reporting, and ensuring adequate long-term follow-up will strengthen the evidence base. As minimally invasive surgeries evolve, these efforts will help optimize patient care and resource utilization in HCC management. Transparency Statement: This research is reported in line with the TITAN Guidelines for transparency in the use of artificial intelligence[6]. The author declares that no artificial intelligence tools were used in the creation of this manuscript.