Open access peer-reviewed chapter

Minimally Invasive Surgery for Hepatocellular Carcinoma; Latest Advances

Written By

Alexandros Giakoustidis, Apostolos Koffas, Dimitrios Giakoustidis and Vasileios N. Papadopoulos

Submitted: 20 June 2021 Reviewed: 09 August 2021 Published: 04 October 2021

DOI: 10.5772/intechopen.99840

From the Edited Volume

Hepatocellular Carcinoma - Challenges and Opportunities of a Multidisciplinary Approach

Edited by Georgios Tsoulfas

Chapter metrics overview

186 Chapter Downloads

View Full Metrics

Abstract

Surgical resection is the gold standard for hepatocellular carcinoma management for early stages of the disease. With advances in technology and techniques, minimally invasive surgery provides a great number of advantages for these patients during their surgery and for their post-operative care. The selection of patients following a multi-disciplinary approach is of paramount importance. Adding to this, the developments in laparoscopic instruments and training, as well as the promising advantages of robotic surgery along with other forms of technology, increase the pool of patients that can undergo operation safely and with good results worldwide. We review results from great centres worldwide and delineate the accurate multi-disciplinary approach for this.

Keywords

  • laparoscopic
  • robotic
  • minimally invasive surgery
  • hepatocellular carcinoma

1. Introduction

Liver cancer is the 5th most common cancer and the second most frequent cause of cancer-related death globally, with 854,000 new diagnoses and 810,000 deaths per year [1, 2]. Hepatocellular carcinoma (HCC) accounts for approximately 90% of liver cancers and is generally associated with an unfavorable prognosis, with a 5-year overall survival (OS) of 10–15%, mostly due to a delay in establishing an early diagnosis. In case HCC is diagnosed at an earlier stage, the 5-year OS improves and may reach 70%, amid the possibility of curative treatments, such as liver resection (LR), liver transplantation (LT) and ablation [3, 4].

Advertisement

2. Minimally invasive surgery for HCC

2.1 Staging systems and treatment allocation

Once diagnosed, prognostication is pivotal in the management of HCC. Disease staging and classification is intended to assess prognosis and determine treatment candidacy. In patients with HCC, the co-existence of two life-threatening conditions, i.e., cancer and cirrhosis, needs to be tackled with, and further complicates prognostic assessment [5, 6]. The 2018 European Association for the Study of the Liver (EASL) clinical practice guidelines endorsed the Barcelona Clinic Liver Cancer (BCLC) classification [7], as did the recent American Association for the Study of Liver Diseases (AASLD) guidance [3]. According to the BCLC classification system, patients are classified into five stages (0, A, B, C and D) according to pre-established prognostic variables. These variables comprise tumor characteristics (size, number, vascular invasion, lymph node involvement, distant metastases), liver function (bilirubin, portal hypertension, liver function preservation) and patient’s health status (ECOG).

2.2 Liver resection

Determining eligibility for LR involves assessment of the tumor burden; assessment of liver function; the extent of hepatectomy and the expected volume of the future liver remnant; and the presence of portal hypertension and other co-morbidities. Liver function is objectively estimated by the Child-Pugh score and patients with Child-Pugh B or C are deemed at a high risk of liver failure following LR, even after a minor resection. More recently, the model for end-stage liver disease (MELD) score was integrated into the EASL guidelines for treatment allocation [7, 8]. The absence of cirrhosis allows for larger and more complex resections, and is associated with viable postoperative mortality and morbidity, even after major hepatic resection, with a 5-year OS of 50% [9, 10, 11, 12, 13]. Conversely, clinically significant portal hypertension (CSPH), defined as HVPG >10 mmHg, is a well-established predictor of liver decompensation and death after LR [14, 15, 16, 17, 18].

Surgery represents the backbone of HCC treatment, resulting in the best outcomes in appropriately-selected candidates. LR and LT represent the first-line treatment in individuals with early-stage tumors on an intention-to-cure perspective. In particular, the latest EASL guidance recommends LR in cases of a resectable solitary nodule without macrovascular invasion and extrahepatic spread, regardless of size [7, 19]. The AASLD guidelines advocate LR in patients with Child-Pugh A compensated cirrhosis and resectable HCC, i.e., solitary tumor <5 cm with or without vascular invasion, or multifocal tumor <5 cm [3]. Finally, the Asian Pacific Association for the Study of the Liver (APASL) recommends that all tumors without extrahepatic spread may be considered for LR, regardless of vascular invasion, number and size of lesions [4].

2.3 A laparoscopic approach

The advent of laparoscopic techniques transformed the treatment landscape of HCC. In spite of the relative paucity of prospective randomized studies, the laparoscopic approach appears to convey similar oncological outcomes with respect to conventional surgery [20]. Laparoscopic LR allows the preservation of the abdominal wall, minimizes peritoneal trauma, and is associated with fewer complications in comparison with open surgery, including both overall and liver-related complications, as also shown in a recent meta-analysis including 6,812 patients. Additionally, no differences in operative time, blood loss, intraoperative complications, hospital stay, and morbidity were found in laparoscopic LR for cirrhotics in comparison with non-cirrhotics [21, 22, 23, 24, 25, 26, 27, 28]. Several studies demonstrated that minimally-invasive surgical techniques in patients with cirrhosis are associated with reduced risk of post-operative hepatic decompensation and liver failure [29, 30, 31]. Interestingly, this technique also appears safe in the elderly, even for a major hepatectomy, and is associated with improved outcomes [32, 33, 34, 35, 36]. One should bear in mind though that laparoscopic hepatectomy should be carried out in specialist centres and following appropriate training and education of all team members involved. The importance of this factor is highlighted as the keys to successful LR include technical mastering of laparoscopic hepatic portal occlusion which can be more challenging than in laparotomy, and the lack of operational feel and need for rapid reactive mode as well as accurate hemostasis.

In light of the above, EASL 2018 clinical practice guidelines recommend laparoscopic LR for HCC resection in expert centres and for selected surgical candidates [7]. Similarly, the AASLD also recognizes the advantages of laparoscopic techniques in selected scenarios [3]. EASL recommends [7] that tumor size and location should determine optimal surgical approach. In particular, laparoscopic-robotic LR for HCC may be considered for tumors located in superficial peripheral positions of the liver; and is associated with optimal survival outcomes, low complication rate and reduced inpatient time. Minimally-invasive LR can be an effective option in very early (≤2 cm) and early HCC. Ablation represents still the treatment modality of choice for this disease stage, owing to the higher cost-effectiveness [16] and to milder liver function impact. However, several studies report that patients treated with minimally-invasive LR for such tumors, mainly located in superficial or antero-lateral positions, suffer less adverse outcomes and shorter hospitalization, in comparison with conventional open techniques, while achieving competitive oncologic results with respect to ablation [37, 38, 39, 40].

Limited resections conducted via laparoscopic LR may also be considered for curative resection in selected patients with HCC with a borderline liver profile (i.e., Child Pugh B7, moderate portal hypertension and/or bilirubin around 2 mg/dl), especially in specialized centres [7]. A study reported that patients with Child-Pugh A and Child-Pugh B/C cirrhosis who underwent laparoscopic LR had a similar perioperative course [26]. Laparoscopic LR has also been explored as an option for patients with CSPH. A recent study by Lim et al assessed the short-term outcomes in patients with and without CSPH [41]. Although broadening eligibility criteria for minimally-invasive techniques would increase the rate LR, morbidity and hospital stay would be a significant concern for patients with CSPH. In light of the above, LT remains the gold standard in cases of HCC and advanced liver disease. Nevertheless, the laparoscopic approach may be beneficial prior to LT for HCC, with significantly reduced de-listing and death after LT when prior LR was performed laparoscopically [42]. Whether laparoscopic LR should also be considered in patients with HCC and CSPH not eligible for LT, will need to be addressed with further studies. Lastly, the safety and feasibility of laparoscopic major hepatectomy has been reported after sequential transarterial chemoembolization (TACE), which is classically associated with increased surgical difficulty [43]. Additionally, laparoscopic LR can be applied in living donor liver transplantation (LDLT) in centres with extensive experience in both laparoscopic LR and open LDLT.

2.4 Robotic liver surgery

Similar to laparoscopic LR, robotic LR is also emerging as an interesting minimally-invasive surgical technique, demonstrating a relative safe profile and allowing for an easier access to hepatic segments not amenable to laparoscopic approach, such as posterior sectionectomies and resection of tumors located in superior segments 4a and 8 [44]. The development of minimally invasive surgical techniques for liver tumors is in general limited by the characteristics of the liver itself, such as its texture, abundant blood supply, an increased number of structural variations of blood vessels and bile ducts.

A recent literature review including 10 studies on robotic liver resection for HCC (with a total of 302 patients) reported disease-free (DFS) and OS at 2 years of 72–84% and 94–98%, respectively [44]. It has also been proposed that a robotic approach may also improve the access to the abdomen in cases of recurrent disease with potential requirement of LT, expanding the opportunities of both down-staging and bridging strategies [45]. The broad use of the robotic approach, however, is limited due to several factors, most importantly the cost of the robotic surgical devices compared to laparoscopic equipment. Several analyses on costs of robotic surgery have been reported, with controversial findings regarding the balance between costs and benefits [46, 47, 48, 49, 50, 51]. With regard to instrumentation, the lack of an efficient robotic transection device such as the Ultasonographic Aspirator (UA) is the most important limitation of robotic liver surgery. Another limitation would be the spatial distance between the operating and robotic platform and its considerable size, making undocking and gaining access to the patient particularly challenging in emergency scenarios [52, 53]. Lastly, a non-negligible obstacle of robotic surgery is the operative time, that is in the majority longer in comparison with other surgical approaches. In view of the above, robotic LR needs to be better evaluated before being integrated into routine clinical practice and therapeutic algorithms. On the other hand, however, robotic LR can overcome certain traditional laparoscopic liver resection limitations like the inflexible fixation of the operating instruments as well as visual result [54]. The Robotic System appears superior in regard to these limitations and there are constant developments in the field as per instruments applied crucial to LR. At present, the Da Vinci Robotic surgical assistant system is in use in several centres for both benign and malignant liver diseases with similar indications applied as per the laparoscopic LR, and in certain cases demonstrating a more advantageous nature [55].

2.5 Cost of minimally invasive surgery

The results so far comparing robotic to laparoscopic and open LR are conflicting as per the cost effect to the institution hosting them. A single institution retrospective study from the University of Washington compared cost data for 71 robotic LR to 88 open procedures and reported that although there were higher perioperative costs for the robotic procedures, the postoperative costs and subsequent direct hospital costs were lower when compared with open procedures, attributing this possibly to a 2-day shorter hospital stay on average after robotic procedures [56]. On the other hand other studies have demonstrated a higher cost for robotic LR when compared to both laparoscopic and open procedures although in some the trend of less hospital stay was in favor of the robotic procedures [57, 58, 59].

2.6 Emerging technologies

Recent advances in liver surgery from a technological aspect include near-infrared fluorescent (NIF) imaging applied intra-operatively. NIF imaging has been set in use in several laparoscopic and robotic camera systems enabling the identification of various dyes, such as indocyanine green, injected preoperatively. Indocyanine green is a green dye that is preferentially metabolized by hepatocytes and excreted in the biliary tree and it lights up the biliary tree. Its use has been utilized for robotic and laparoscopic assisted cholecystectomy. It has also been more recently applied for a more accurate parenchymal dissection following vascular control by identifying perfused from poorly perfused hepatic parenchyma [60].

Future advances of robotic liver surgery include the application of preoperative planning with virtual reality (VR) models and real-time augmented reality (AR) intra- operative endoscopic overlays to assist with surgical navigation on da Vinci ® surgical systems. Computer-based three-dimensional (3D) reconstructions of liver tumors have been shown to benefit the accuracy of tumor localization and precision of operative planning for liver surgery [61, 62]. Intraoperative Ultrasound is routinely used for real-time identification of liver tumors both in open and minimally invasive LR. However, with AR being developed to overlay accurate 3D reconstruction data onto the operative field itself, it can potentially eliminate the need to divert the attention from the operative field and to translate the 2D images into a 3D construct.

Advertisement

3. Conclusions

With the constant evolution of technology, it would be without a doubt that surgery techniques in terms of access and instrument implementation would evolve as well. Laparoscopic liver surgery appears to have gained considerable ground especially in centres where liver surgery and laparoscopic expertise co-exist. The robotic approach is still quite variable between institutions, as well as between countries and continents. Thus one can only anticipate for advances in minimally invasive surgery to continue as long as there are specialized liver centres aiming to increase patient volume undergoing surgery and decrease hospital stay, complications rates and in general offer the best possible liver service.

Advertisement

Conflict of interest

“The authors declare no conflict of interest.”

References

  1. 1. Akinyemiju T, Abera S, Ahmed M, Alam N, Alemayohu MA, Allen C, et al. The burden of primary liver cancer and underlying etiologies from 1990 to 2015 at the global, regional, and national level. JAMA Oncol 2017;3:1683-1691.
  2. 2. Fact Sheets by Population-Globocan-IARC n.d. http://globocan.iarc.fr/ Pages/fact_sheets_population.aspx (accessed December 18, 2017)
  3. 3. Marrero JA, Kulik LM, Sirlin CB, Zhu AX, Finn RS, Abecassis MM, et al. Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2018;68(2):723-750.
  4. 4. Omata M, Cheng AL, Kokudo N, Kudo M, Lee JM, Jia J, et al. Asia-Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update. Hepatol Int 2017;11(4):317-370.
  5. 5. Setiawan VW, Wilkens LR, Lu SC, Hernandez BY, Le Marchand L, Henderson BE. Association of coffee intake with reduced incidence of liver cancer and death from chronic liver disease in the US multiethnic cohort. Gastroenterology 2015;148:118-25; quiz e15.
  6. 6. Sorrentino P, Tarantino L, D’Angelo S, Terracciano L, Ferbo U, Bracigliano A, et al. Validation of an extension of the international non-invasive criteria for the diagnosis of hepatocellular carcinoma to the characterization of macroscopic portal vein thrombosis. J Gastroenterol Hepatol 2011;26:669-677.
  7. 7. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol . 2018 Jul;69(1):182-236. doi: 10.1016/j.jhep.2018.03.019.
  8. 8. Vitale A, Burra P, Frigo AC, Trevisani F, Farinati F, Spolverato G, et al. Survival benefit of liver resection for patients with hepatocellular carcinoma across different Barcelona Clinic Liver Cancer stages: a multicentre study. J Hepatol 2015;62(3):617-624.
  9. 9. Smoot RL, Nagorney DM, Chandan VS, Que FG, Schleck CD, Harmsen WS, et al. Resection of hepatocellular carcinoma in patients without cirrhosis. Br J Surg 2011;98(5):697-703.
  10. 10. Thelen A, Benckert C, Tautenhahn HM, Hau HM, Bartels M, Linnemann J, et al. Liver resection for hepatocellular carcinoma in patients without cirrhosis. Br J Surg 2013;100(1):130-137.
  11. 11. Lewis RH, Glazer ES, Bittenbinder DM, O’Brien T, Deneve JL, Shibata D, et al. Outcomes following resection of hepatocellular carcinoma in the absence of cirrhosis. J Gastrointest Cancer 2019;50(4):808-815.
  12. 12. Lang H, Sotiropoulos GC, Dömland M, Frühauf NR, Paul A, Hüsing J, et al. Liver resection for hepatocellular carcinoma in non-cirrhotic liver without underlying viral hepatitis. Br J Surg 2005;92(2):198-202.
  13. 13. Llovet JM, Fuster J, Bruix J. Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation. Hepatology 1999;30(6):1434-1440
  14. 14. de Franchis R, Faculty BV. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010;53(4):762-768.
  15. 15. Ishizawa T, Hasegawa K, Aoki T, Takahashi M, Inoue Y, Sano K, et al. Neither multiple tumors nor portal hypertension are surgical contraindications for hepatocellular carcinoma. Gastroenterology 2008;134(7):1908-1916.
  16. 16. Cucchetti A, Piscaglia F, Cescon M, Ercolani G, Terzi E, Bolondi L, et al. Conditional survival after hepatic resection for hepatocellular carcinoma in cirrhotic patients. Clin Cancer Res 2012;18(16):4397-4405.
  17. 17. Roayaie S, Jibara G, Tabrizian P, Park J-W, Yang J, Yan L, et al. The role of hepatic resection in the treatment of hepatocellular cancer. Hepatology 2015;62(2):440-451.
  18. 18. Berzigotti A, Reig M, Abraldes JG, Bosch J, Bruix J. Portal hypertension and the outcome of surgery for hepatocellular carcinoma in compensated cirrhosis: a systematic review and meta-analysis. Hepatology 2015;61:526-536.
  19. 19. European Association for the Study of the Liver, European Organisation for Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 2012;56(4):908-943.
  20. 20. Goumard C, Farges O, Laurent A, Cherqui D, Soubrane O, Gayet B, et al. An update on laparoscopic liver resection: the French Hepato-Bilio-Pancreatic Surgery Association statement. J Visc Surg 2015;152(2):107-112.
  21. 21. Cherqui D, Laurent A, Tayar C, Chang S, Van Nhieu JT, Loriau J, et al. Laparoscopic liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: midterm results and perspectives. Ann Surg 2006;243(4):499-506.
  22. 22. Sarpel U, Hefti MM, Wisnievsky JP, Roayaie S, Schwartz ME, Labow DM. Outcome for patients treated with laparoscopic versus open resection of hepatocellular carcinoma: case-matched analysis. Ann Surg Oncol 2009;16(6):1572-1577.
  23. 23. Nguyen KT, Marsh JW, Tsung A, Steel JJL, Gamblin TC, Geller DA. Comparative benefits of laparoscopic vs open hepatic resection: a critical appraisal. Arch Surg 2011;146(3):348-356.
  24. 24. Kasai M, Cipriani F, Gayet B, Aldrighetti L, Ratti F, Sarmiento JM, et al. Laparoscopic versus open major hepatectomy: a systematic review and meta-analysis of individual patient data. Surgery 2018;163(5):985-995.
  25. 25. Di Sandro S, Danieli M, Ferla F, Lauterio A, De Carlis R, Benuzzi L, et al. The current role of laparoscopic resection for HCC: a systematic review of past ten years. Transl Gastroenterol Hepatol 2018;3:68.
  26. 26. Morise Z, Sugioka A, Kawabe N, Umemoto S, Nagata H, Ohshima H, et al. Pure laparoscopic hepatectomy for hepatocellular carcinoma patients with severe liver cirrhosis. Asian J Endosc Surg 2011;4(3):143-146.
  27. 27. Xiangfei M, Yinzhe X, Yingwei P, Shichun L, Weidong D. Open versus laparoscopic hepatic resection for hepatocellular carcinoma: a systematic review and meta-analysis. Surg Endosc 2019;33(8):2396-2418.
  28. 28. Abu Hilal M, Aldrighetti L, Dagher I, Edwin B, Troisi RI, Alikhanov R, et al. The Southampton consensus guidelines for laparoscopic liver surgery: from indication to implementation. Ann Surg 2018;268(1):11-18.
  29. 29. Roayaie S, Obeidat K, Sposito C, Mariani L, Bhoori S, Pellegrinelli A, et al. Resection of hepatocellular cancer ≤2 cm: Results from two Western centers. Hepatology 2013;57:1426-1435.
  30. 30. Han H-S, Shehta A, Ahn S, Yoon Y-S, Cho JY, Choi Y. Laparoscopic vs. open liver resection for hepatocellular carcinoma: Case – matched study with propensity score matching. J Hepatol 2015;63:643-650.
  31. 31. Sposito C, Battiston C, Facciorusso A, Mazzola M, Muscara C, Scotti M, et al. Propensity score analysis of outcomes following laparoscopic or open liver resection for hepatocellular carcinoma. Br J Surg 2016;103:871-880.
  32. 32. Amato B, Aprea G, De Rosa D, Milone M, di Domenico L, Amato M, et al. Laparoscopic hepatectomy for HCC in elderly patients: risks and feasibility. Aging Clin Exp Res 2017;29(Suppl 1):179-183.
  33. 33. Nomi T, Hirokawa F, Kaibori M, Ueno M, Tanaka S, Hokuto D, et al. Laparoscopic versus open liver resection for hepatocellular carcinoma in elderly patients: a multi-centre propensity score-based analysis. Surg Endosc 2020;34(2):658-666.
  34. 34. Yu X, Yan YC, Chen G, Yu H. The efficacy and safety of totally laparoscopic hepatectomy for non-cirrhotic hepatocellular carcinoma in the elderly. BMC Surg 2018;18(1):118.
  35. 35. Andert A, Lodewick T, Ulmer TF, Schmeding M, Schöning W, Neumann U, et al. Liver resection in the elderly: a retrospective cohort study of 460 patients - feasible and safe. Int J Surg 2016;28:126-130.
  36. 36. Cauchy F, Fuks D, Nomi T, Dokmak S, Scatton O, Schwarz L, et al. Benefits of laparoscopy in elderly patients requiring major liver resection. J Am Coll Surg 2016;222(2):174-184.e10.
  37. 37. Soubrane O, Goumard C, Laurent A, Tranchart H, Truant S, Gayet B, et al. Laparoscopic resection of hepatocellular carcinoma: a French survey in 351 patients. HPB 2014;16:357-365.
  38. 38. Parks KR, Kuo Y-H, Davis JM, O’ Brien B, Hagopian EJ. Laparoscopic vs. open liver resection: a meta-analysis of long-term outcome. HPB (Oxford) 2014;16:109-18.
  39. 39. Morise Z, Ciria R, Cherqui D, Chen K-H, Belli G, Wakabayashi G. Can we expand the indications for laparoscopic liver resection? A systematic review and meta-analysis of laparoscopic liver resection for patients with hepatocellular carcinoma and chronic liver disease. J Hepatobiliary Pancreat Sci 2015;22:342-352.
  40. 40. Takahara T, Wakabayashi G, Beppu T, Aihara A, Hasegawa K, Gotohda N, et al. Long-term and perioperative outcomes of laparoscopic vs. open liver resection for hepatocellular carcinoma with propensity score matching: a multi-institutional Japanese study. J Hepatobiliary Pancreat Sci 2015;22:721-727.
  41. 41. Lim C, Osseis M, Lahat E, Doussot A, Sotirov D, Hemery F, et al. Safety of laparoscopic hepatectomy in patients with hepatocellular carcinoma and portal hypertension: interim analysis of an open prospective study. Surg Endosc 2019;33(3):811-820.
  42. 42. Levi Sandri GB, Lai Q, Ravaioli M, DI Sandro S, Balzano E, Pagano D, et al. The role of salvage transplantation in patients initially treated with open vs minimally invasive liver surgery: an intention-to-treat analysis. Liver Transpl 2020;26(5):878-887.
  43. 43. Goumard C, Komatsu S, Brustia R, Fartoux L, Soubrane O, Scatton O. Technical feasibility and safety of laparoscopic right hepatectomy for hepatocellular carcinoma following sequential TACE-PVE: a comparative study. Surg Endosc 2017;31(5):2340-2349.
  44. 44. Magistri P, Tarantino G, Assirati G, Olivieri T, Catellani B, Guerrini GP, et al. Robotic liver resection for hepatocellular carcinoma: a systematic review. Int J Med Robot 2019;15(4):e2004.
  45. 45. Magistri P, Olivieri T, Assirati G, Guerrini GP, Ballarin R, Tarantino G, et al. Robotic Liver Resection Expands the Opportunities of Bridging Before Liver Transplantation. Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc. 2019 Jul;25(7):1110-2.
  46. 46. Giulianotti PC, Coratti A, Sbrana F, Addeo P, Bianco FM, Buchs NC, et al. Robotic liver surgery: results for 70 resections. Surgery 2011;149(1) :29-39.
  47. 47. Lai ECH, Yang GPC, Tang CN. Robot-assisted laparoscopic liver resection for hepatocellular carcinoma: short-term outcome. Am J Surg 2013;205(6):697-702.
  48. 48. Chen P-D, Wu C-Y, Hu R-H, Chou W-H, Lai H-S, Liang J-T, et al. Robotic versus open hepatectomy for hepatocellular carcinoma: a matched comparison. Ann Surg Oncol 2017;24(4):1021-1028.
  49. 49. Magistri P, Tarantino G, Guidetti C, Assirati G, Olivieri T, Ballarin R, et al. Laparoscopic versus robotic surgery for hepatocellular carcinoma: the first 46 consecutive cases. J Surg Res 2017;217:92-99.
  50. 50. Mejia A, Cheng SS, Vivian E, Shah J, Oduor H, Archarya P. Minimally invasive liver resection in the era of robotics: analysis of 214 cases. Surg Endosc. 2020;34(1):339-48.
  51. 51. Cortolillo N, Patel C, Parreco J, Kaza S, Castillo A. Nationwide outcomes and costs of laparoscopic and robotic vs. open hepatectomy. J Robot Surg. 2019;13(4):557-65.
  52. 52. Di Benedetto F, Magistri P, Halazun KJ. Use of robotics in liver donor right hepatectomy. Hepatobiliary Surg Nutr. 2018;7(3):231-2.
  53. 53. Miller C. Preparing for the inevitable: The death of a living liver donor. Liver Transplant. Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc. 2014;20 Suppl 2:S47-51.
  54. 54. Hu L, Yao L, Li X, Jin P, Yang K, Guo T. Effectiveness and safety of robotic-assisted versus laparoscopic hepatectomy for liver neoplasms: a meta-analysis of retrospective studies. Asian J Surg 2018;41:401-16
  55. 55. Gonzalez-Ciccarelli LF, Quadri P, Daskalaki D, Milone L, Gangemi A, Giulianotti PC. Robotic approach to hepatobiliary surgery. Chirurg 2017;88:19-28.
  56. 56. Sham JG, Richards MK, Seo YD, Pillarisetty VG, Yeung RS, Park JO. Efficacy and cost of robotic hepatectomy: is the robot cost- prohibitive? J Robot Surg. 2016;10(4):307-313.
  57. 57. Ji WB, Wang HG, Zhao ZM, Duan WD, Lu F, Dong JH. Robotic- assisted laparoscopic anatomic hepatectomy in China: initial experience. Ann Surg. 2011;253(2):342-348
  58. 58. Yu YD, Kim KH, Jung DH, et al. Robotic versus laparoscopic liver resection: a comparative study from a single center. Langen- becks Arch Surg. 2014;399(8):1039-1045
  59. 59. Beard RE, Tsung A. Minimally Invasive Approaches for Surgical Management of Primary Liver Cancers Cancer Control. 2017 Jul-Sep;24(3):1073274817729234.
  60. 60. Labadie K, Sullivan K.M. and O. Park J. Surgical Resection in HCC. Liver Cancer http://dx.doi.org/10.5772/intechopen.81345
  61. 61. Lamadé W, Glombitza G, Fischer L, et al. The impact of 3-dimensional reconstructions on operation planning in liver surgery. Archives of Surgery. 2000;135(11):1256-1261
  62. 62. Bangeas P, Tsioukas V, Papadopoulos VN, Tsoulfas G. Role of innovative 3D printing models in the management of hepatobiliary malignancies. J Hepatol 2019 Jul 27;11(7):574-585. doi: 10.4254/wjh.v11.i7.574.

Written By

Alexandros Giakoustidis, Apostolos Koffas, Dimitrios Giakoustidis and Vasileios N. Papadopoulos

Submitted: 20 June 2021 Reviewed: 09 August 2021 Published: 04 October 2021