Textbook outcome after robotic liver surgery at a high-volume Scandinavian HPB center: an IWATE-based difficulty-stratified assessment of 200 cases

BACKGROUND: Textbook outcome (TO) provides a patient-centered composite measure of perioperative quality in liver surgery. Although robotic liver surgery (RLS) is increasingly adopted, data applying internationally harmonized TO definitions to RLS remain limited, particularly when interpreted according to procedural difficulty. METHODS: We reviewed 200 consecutively performed RLSs at a high-volume hepatopancreatobiliary center in Denmark. TO after RLS (TORLS) was assessed by applying the internationally established Delphi consensus definition of textbook outcome in liver surgery to the RLS cohort. For clarity, this endpoint is referred to descriptively as TORLS, although no new robotic-specific textbook outcome definition was created. The components were: no intraoperative incident grade ≥ 2 (modified Oslo classification), no bile leakage grade B/C, no post-hepatectomy liver failure grade B/C, no Clavien-Dindo grade ≥ III complications within 90 days, no surgery-related (Clavien-Dindo grade ≥ III) readmission within 90 days, no in-hospital/90-day mortality, and R0 resection (malignant tumors; resection margin ≥ 1mm). TORLS + additionally required no occurrence of prolonged hospitalization (over 3 days for minor resection, over 5 days for major resection). Surgical difficulty was assessed using the IWATE criteria and classified dichotomously (≤ 6 vs ≥ 7). RESULTS: Of 210 RLS cases assessed, 10 were excluded: safety-driven change in operative strategy after intraoperative liver assessment (n = 5) and missing data required to adjudicate TORLS components and/or 90-day follow-up (n = 5). The analysis included 200 cases (IWATE ≤ 6: 123 cases, IWATE ≥ 7: 77 cases). Overall, TORLS was achieved in 155/200 (77.5%) cases, and TORLS+ was achieved in 119/200 (59.5%) cases. TORLS was achieved in 100/123 (81.3%) cases in the IWATE ≤ 6 group and in 55/77 (71.4%) cases in the IWATE ≥ 7 group. TORLS+ achievement rates were 78/123 (63.4%) and 41/77 (53.2%), respectively. The most frequent limiting factor was prolonged hospitalization. CONCLUSION: In this single-center Danish cohort of 200 RLS cases, TORLS and TORLS+ achievement rates were numerically lower in procedures with higher IWATE difficulty scores; these differences did not reach statistical significance. Consensus-based TO assessment after RLS was feasible and may provide difficulty-stratified institutional reference values for internal quality monitoring.