Stepwise increasing complexity in the learning process of robotic major liver resection with hepatico-jejunostomy

Background Cholangiocarcinoma (CCA) represents the most common biliary tract malignancy, and the second most common primary hepatic malignancy, accounting for 15% to 20% of primary liver tumours. Perihilar cholangiocarcinoma (pCCA) involves the biliary confluence with or without involvement of the right and left hepatic ducts. Complete resection with negative histologic margins is the only chance of cure and the most robust predictor of long-term survival for patients affected by any type of locally advanced CCA. However, the proximity of perihilar tumors to vital structures makes curative excision technically difficult. Minimally invasive approaches are progressively spreading in liver surgery units worldwide. Significant advantages of minimally invasive liver resections, if compared to open one, have been diffusely shown, such as shorter hospital stay and possibility of complex reconstructive procedures similar to those performed in open surgery. Robot-assisted liver surgery represents a natural consequence of such a minimally invasive evolution and is increasingly adopted in liver surgery, exploiting benefits like 3D magnification and enhanced precision. Purpose of the study This study aims to evaluate the initial outcomes, feasibility and safety of robotic major hepatic resections with biliary and vascular reconstruction in our institutional series performed at the Hepatobiliary Surgery and Liver Transplantation Unit of the University of Padova. To assess the learning curve associated with the robotic surgical technique, we conducted a comparative analysis between early experience cases, defined as patients operated on between 2018 and 2023, and late experience cases, which were performed in 2024. Materials and methods We conducted a prospective study involving 25 patients who underwent robotic major resections with biliary and/or vascular reconstruction for suspected perihilar cholangiocarcinoma (pCCA), including Bismuth-Corlette 3a, 3b and 4, using the da Vinci Xi platform from January 2018 to November 2024. Results Twenty-five patients underwent major liver resection for perihilar cholangiocarcinoma utilizing the robotic technique. The median age was 67 years, and 56% of the patients underwent preoperative biliary drainage. Median operative time was 735 minutes with a median estimated blood loss of 550 mL. Seventeen patients were histologically confirmed of pCCA, Klatskin type-3b was the most common. The number of harvested lymph nodes was four, and 7 (28%) patients yielded positive lymph nodes. Four patients required vascular reconstruction, three of the performed fully robotics; 20% of patients had >1 biliary anastomosis. R0 resection margins were achieved in 88,8% of patients. Clavien-Dindo Grade ≥3 complications were seen in 32% of patients, with a median Comprehensive Complication Index (CCI®) of 22,6. The length of stay was 11 days with a time to functional recovery of 5 days. Seven patients had an unplanned readmission within 30 days. One patient died within 90 days. Conclusions While recent literature on robotic liver surgery is limited and often presents heterogeneous data regarding surgical indications and techniques, our study focused solely on major hepatic and biliary resections. This study shows that robotic major hepatectomies with biliary reconstruction technique is safe, feasible and effective, providing acceptable surgical outcomes with manageable morbidity and should therefore be considered as a valuable alternative to the open technique.