Robotic liver resection in minimally invasive expert centers is associated with a very low rate of bile leakage: results from a national multicenter cohort

Bile leakage remains one of the most relevant complications after liver resection, contributing substantially to postoperative morbidity. Although minimally invasive liver surgery has reduced biliary complications compared with open approaches, robust multicenter data specifically evaluating bile leakage after robotic liver resection in expert centers remain limited. To assess bile leak incidence and severity following robotic liver resection in expert centers. This national, multicenter observational database included all consecutive adult patients undergoing robotic liver resection in three high-volume reference centers. Patients requiring biliary diversion or living donor procedures were excluded. Perioperative outcomes were prospectively collected, focusing on postoperative bile leakage, defined and graded according to the International Study Group of Liver Surgery (ISGLS) criteria. Secondary outcomes included overall morbidity, conversion rate, mortality, and length of hospital stay. A total of 492 patients were included. Malignant disease was the primary indication in 80% of cases, and 62% of resections were anatomical. Conversion to open or laparoscopic surgery occurred in 2.6%. Postoperative bile leakage occurred in 9 patients (1.8%). According to ISGLS classification, 6 patients (67%) developed Grade A bile leaks and 3 patients (33%) Grade B leaks; no Grade C bile leaks were observed. All biliary complications were managed conservatively or with minimally invasive interventions, without the need for surgical reintervention. Overall postoperative morbidity within 90 days was 29.3%, with a 90-day mortality of 1.6%. Median length of stay was 3 days (IQR 3-5). In this national multicenter cohort from expert centers, robotic liver resection was associated with a very low incidence of bile leakage and an absence of severe (Grade C) biliary complications. These findings support the safety of robotic liver surgery and highlight the key role of high-volume centralization in keeping biliary outcomes.