ArticleSurgical endoscopy2026
Minimally invasive versus open liver resection for benign disease: analysis of textbook outcomes according to difficulty of resections and role of the robotic approach.
Article in Surgical endoscopy, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundMinimally invasive liver resection (MILR) has been increasingly adopted for benign liver diseases (BLD), although its impact on composite outcome measures and its role at different levels of procedural complexity remain unclear. This study aimed to evaluate the efficacy of MILR compared to open liver resection (OLR), with a specific focus on textbook outcomes (TO) and the contribution of the robotic approach.
methodsFor this cohort study, a retrospective analysis of 536 liver resections for BLD performed at a tertiary referral center (2004-2023) was conducted. After 1:2 propensity score matching, 150 OLR and 300 MILR were compared. Outcomes were assessed overall and stratified by surgical difficulty (low, intermediate, high). The primary endpoints were essential textbook outcomes (TOLS) and extended textbook outcomes (TOLS +) achievement. Multivariable analysis identified predictors of achieving TO.
resultsMILR was associated with reduced blood loss (300 vs. 500 mL, p = 0.031), lower transfusion rates (4.0% vs. 9.3%, p = 0.027), fewer intraoperative adverse events (4.0% vs. 7.3%, p = 0.035), lower morbidity (9.7% vs. 18.7%, p = 0.023), and shorter hospital stay (5 vs. 7 days, p = 0.021). TOLS and TOLS + were achieved more frequently after MILR (87.3% vs. 78.7%, p = 0.038; 74.7% vs. 48.7%, p = 0.008). Stratified analysis by difficulty showed that complex MILR was associated with higher rates of achieving both TOLS and TOLS + compared to OLR (p = 0.025 and p = 0.004); low- and intermediate-difficulty MILR showed advantages only in terms of TOLS + (p = 0.006 and p = 0.008). The robotic approach was adopted more frequently in complex cases and was independently associated with a higher probability of achieving TOLS (OR 2.55, p = 0.003).
conclusionsMILR improves perioperative outcomes and increases the likelihood of achieving optimal composite outcomes in BLD. The advantage of MILR in terms of essential TO is limited to complex resections, where the robotic approach appears to be more frequently implemented. Integrating robotics into minimally invasive programs could further improve the efficacy of MILR in this setting.
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