E289: Open Vs Robotic Hepatectomy For Primary Hepatobiliary Malignancy: Validated Outcomes And Survival Analysis

The impact of robotic surgery based on validated perioperative and long-term oncologic outcomes remains uncertain. Our aim was to evaluate the difference in outcomes of robotic compared to open hepatectomy using validated outcome measures and survival analysis.

Methods:

A retrospective review of a prospectively maintained database of all adult hepatectomies (2018 – 2022) was performed. Intraoperative adverse events were reported using the validated ClassIntra system. ISGLS classification systems were employed for reporting postoperative complications. Complexity scores were calculated based on Strasberg classification to quantitatively assess liver resections.

Results:

A total of 203 hepatectomies were identified, 119 (58.6%) for primary hepatobiliary (HPB) pathology, 84 (41.4%) for metastatic liver disease. Among 119 patients, there were 76 (63.8%) hepatocellular carcinoma, 33 (27.7%) cholangiocarcinoma, 8 gallbladder adenocarcinoma, 2 hepatic angiosarcoma. Out of 119 hepatectomies, 64 (53.7%) were open; 55 (46.2%) were robotic.  Comparison of postoperative outcomes showed that robotic hepatectomy had a lower mean EBL (391 vs. 1075; p=0.001), less likely to require transfusion (9.1% vs 29.7%; p=0.004).  Furthermore, open approach were more likely to exhibit ClassIntra intraoperative incidents ≥ grade 2 (21.9 vs.5.5%) (p=0.009), post-hepatectomy liver failure ISGLS ≥grade 2 (12.5 vs 0%; p=0.006), ISGLS bile leak ≥grade 2 (17.1 vs 1.8%; p=0.002), hemorrhage (23.4 vs. 1.8%; p=0.003) and intrabdominal infection (20.3 vs. 5.5%; p=0.016) compared to robotic counterparts.
Comparison of oncologic outcomes showed that despite 0% of robotic hepatectomies having positive margins, there was no statistically significant difference when compared to open (6.5%) (p=0.075).  Kaplan Meier survival analysis revealed no difference in recurrence-free survival between open (mRFS=27.9 mo) and robotic hepatectomies (mRFS=34.6 mo) (p=0.968). However, patients undergoing open hepatectomy had a significantly lower median overall survival (55.4 mo) compared to robotic approach (NR) (p=0.037). Univariable cox regression analysis showed that robotic approach to liver resection is a predictive variable of overall survival (HR = 0.34; 95% CI: [0.11 - 0.98]). However, on multivariable regression modeling, approach to liver resection was no longer an independent predictor of OS when adjusted for variables of pathologic characteristics (HR = 0.64; 95% CI: [0.18 - 2.26]).

Conclusions:

Our study highlights the substantial impact of adopting a robotic approach in achieving superior postoperative outcomes based on validated outcome metrics with equivalent oncologic and survival outcomes.