Safety and efficacy of robotic repeat hepatectomy compared to laparoscopic and open repeat hepatectomy: a retrospective comparative study

Abstract Repeat hepatectomies are challenging due to adhesions and altered anatomy. Robotic surgery, with enhanced dexterity and visualization, may expand the role of minimally invasive liver surgery (MILS) in this setting. The aim of this study was to explore the safety and efficacy of robotic repeat hepatectomy. We conducted a retrospective cohort study comparing repeat robotic (R-RLR), laparoscopic (L-RLR), and open liver resections (O-RLR) performed between January 2019 and December 2024. The primary outcome was postoperative morbidity. Secondary outcomes included conversion to laparotomy, use of Pringle maneuver, blood loss, hospital stay and postoperative mortality. For oncologic efficacy, rates of negative surgical margins (R0) or equivalent (R1 vascular), recurrences and survival were assessed. Forty-two patients underwent repeat hepatectomy (O-RLR = 15, L-RLR = 13, R-RLR = 14). Over time, O-RLR and L-RLR declined in favor of R-RLR. Main indications were colorectal liver metastases and hepatocellular carcinoma. Groups had similar age and comorbidities; however, cirrhosis and portal hypertension were more frequent in R-RLR. Mean Iwate scores were 6 (O-RLR), 4 (L-RLR), and 5 (R-RLR) (p = 0.240). Postoperative morbidity was significantly lower in L-RLR (7.6%) and R-RLR (7.7%) compared to O-RLR (40%) (p = 0.030). Mean Comprehensive Complication Index was 11.7 (O-RLR), 0.7 (L-RLR), and 0.6 (R-RLR) (p = 0.025). Two L-RLR cases required conversion. Pringle maneuver, blood loss, and hospital stay decreased progressively from O-RLR to L-RLR to R-RLR. There was no postoperative mortality.R0 resection was achieved in 73% (O-RLR), 100% (L-RLR), and 78.5% (R-RLR); R1 vascular rates were 13.3%, 0%, and 21.5%, respectively (p = 0.14). The three groups had similar overall and hepatic recurrence rates; survival (recurrence-free and overall) was also similar. Repeat robotic hepatectomy is safe and provides good oncologic outcomes. The robotic approach may allow MILS in more complex cases, including patients with cirrhosis and portal hypertension.