In parallel with the historical development of minimally invasive surgery, the laparoscopic and robotic approaches are now frequently utilized to perform major abdominal surgical procedures. Nevertheless, the role of the robotic approach in liver surgery is still controversial, and a standardized, safe technique has not been defined yet. This review aims to summarize the currently available evidence and prospects of robotic liver surgery. Minimally invasive liver surgery has been extensively associated with benefits, in terms of less blood loss, and lower complication rates, including liver-specific complications such as clinically relevant bile leakage and post hepatectomy liver failure, when compared to open liver surgery. Furthermore, comparable R0 resection rates to open liver surgery have been reported, thus, demonstrating the safety and oncological efficiency of the minimally invasive approach. However, whether robotic liver surgery has merits over laparoscopic liver surgery is still a matter of debate. In the current literature, robotic liver surgery has mainly been associated with non-inferior outcomes compared to laparoscopy, although it is suggested that the robotic approach has a shorter learning curve, lower conversion rates, and less intraoperative blood loss. Robotic surgical systems offer a more realistic image with integrated 3D systems. In addition, the improved dexterity offered by robotic surgical systems can lead to improved intra and postoperative outcomes. In the future, integrated and improved haptic feedback mechanisms, artificial intelligence, and the introduction of more liver-specific dissectors will likely be implemented, further enhancing the robots’ abilities.

Background: A shift towards parenchymal-sparing liver resections in open and laparoscopic surgery emerged in the last few years. Laparoscopic liver resection is technically feasible and safe, and consensus guidelines acknowledge the laparoscopic approach in the posterosuperior segments. Lesions situated in these segments are considered the most challenging for the laparoscopic approach. The aim of this trial is to compare the postoperative time to functional recovery, complications, oncological safety, quality of life, survival and costs after laparoscopic versus open parenchymal-sparing liver resections in the posterosuperior liver segments within an enhanced recovery setting. Methods: The ORANGE Segments trial is an international multicentre randomised controlled superiority trial conducted in centres experienced in laparoscopic liver resection. Eligible patients for minor resections in the posterosuperior segments will be randomised in a 1:1 ratio to undergo laparoscopic or open resections in an enhanced recovery setting. Patients and ward personnel are blinded to the treatment allocation until postoperative day 4 using a large abdominal dressing. The primary endpoint is time to functional recovery. Secondary endpoints include intraoperative outcomes, length of stay, resection margin, postoperative complications, 90-day mortality, time to adjuvant chemotherapy initiation, quality of life and overall survival. Laparoscopic liver surgery of the posterosuperior segments is hypothesised to reduce time to functional recovery by 2 days in comparison with open surgery. With a power of 80% and alpha of 0.04 to adjust for interim analysis halfway the trial, a total of 250 patients are required to be randomised. Discussion: The ORANGE Segments trial is the first multicentre international randomised controlled study to compare short- and long-term surgical and oncological outcomes of laparoscopic and open resections in the posterosuperior segments within an enhanced recovery programme. Trial registration: ClinicalTrials.gov NCT03270917. Registered on September 1, 2017. Before start of inclusion. Protocol version: version 12, May 9, 2017

An increasing number of liver resections are performed laparoscopically, while laparoscopic resection of lesions in the posterosuperior segments is technically challenging. We aimed to assess the outcomes of laparoscopic and open parenchymal preserving resection of lesions in the posterosuperior segments in a randomised controlled trial. In this multicentre, patient-blinded, superiority randomised controlled trial, patients requiring parenchymal preserving liver resection for tumours in segment 4a, 7, or 8 were enrolled at 17 centres and randomised 1:1 to laparoscopic or open surgery using a minimisation scheme stratifying for centre and lesion size. The primary endpoint was time to functional recovery measured in postoperative days. To detect a difference in time to functional recovery of two days the sample size needed 250 patients, an interim analysis was planned with 125 patients. Patients and outcome assessors were blinded to the allocation. The study was registered on clinicaltrials.gov, NCT03270917. Between November 2017 and November 2021, 251 patients were randomised to laparoscopic (n = 125) or open (n = 126) surgery. The majority of patients had a preoperative diagnosis of cancer (225/246 = 91.5%). Time to functional recovery was 3 days (IQR 3–5) in the laparoscopic group compared to 4 days (IQR 3–5) in the open group (difference −19.2%, 96% CI −28.8% to −8.4%; p < 0.001). Hospital stay was similarly shorter in the laparoscopic group (4 days, IQR 3–5 versus 5 days, IQR 4–7; p < 0.001). There were three deaths in the laparoscopic group (3/122 = 2.5%) and one in the open group (1/124 = 0.8%) within 90 days of resection (p = 0.336). Overall postoperative morbidity, severe morbidity, liver-specific morbidity, and readmission were not statistically significant different between the groups. The radical resection (R0) rate in patients with cancer was comparable (laparoscopic 93/106 = 87.7% versus open 97/113 = 85.8%, p = 0.539). For patients with lesions in the posterosuperior segments of the liver, laparoscopic surgery, as compared to open surgery, reduces time to functional recovery. However, this reduction in time to functional recovery did not meet the hypothesized difference in time to functional recovery of two days. This investigator-initiated trial was funded by 10.13039/100009933 Ethicon (Johnson & Johnson), Cancer Research United Kingdom, and Maastricht University Medical Centre+.

Background: The use of a simultaneous resection (SIMR) in patients with synchronous colorectal liver metastases (sCRLM) has increased over the past decades. However, it remains unclear when a SIMR is beneficial and when it should be avoided. The aim of this retrospective cohort study was therefore to compare the outcomes of a SIMR for sCRLM in different settings, and to assess which factors are independently associated with unfavorable outcomes. Methods: To perform this retrospective cohort study, patients with sCRLM undergoing SIMR (2004–2019) were extracted from an international multicenter database, and their outcomes were compared after stratification according to the type of liver and colorectal resection performed. Factors associated with unfavorable outcomes were identified through multivariable logistic regression. Results: Overall, 766 patients were included, encompassing colorectal resections combined with a major liver resection (n=122), minor liver resection in the anterolateral (n=407), or posterosuperior segments (‘Technically major’, n=237). Minor and technically major resections, compared to major resections, were more often combined with a rectal resection (29.2 and 36.7 vs. 20.5%, respectively, both P=0.003) and performed fully laparoscopic (22.9 and 23.2 vs. 6.6%, respectively, both P = 0.003). Major and technically major resections, compared to minor resections, were more often associated with intraoperative transfusions (42.9 and 38.8 vs. 20%, respectively, both P = 0.003) and unfavorable incidents (9.6 and 9.8 vs. 3.3%, respectively, both P≤0.063). Major resections were associated, compared to minor and technically major resections, with a higher overall morbidity rate (64.8 vs. 50.4 and 49.4%, respectively, both P≤0.024) and a longer length of stay (12 vs. 10 days, both P≤0.042). American Society of Anesthesiologists grades ≥3 [adjusted odds ratio (aOR): 1.671, P=0.015] and undergoing a major liver resection (aOR: 1.788, P=0.047) were independently associated with an increased risk of severe morbidity, while undergoing a left-sided colectomy was associated with a decreased risk (aOR: 0.574, P=0.013). Conclusions: SIMR should primarily be reserved for sCRLM patients in whom a minor or technically major liver resection would suffice and those requiring a left-sided colectomy. These findings should be confirmed by randomized studies comparing SIMR with staged resections.