Clinical and economic outcomes of robotic-assisted, laparoscopic, and open liver resection in BCLC 0/A hepatocellular carcinoma: a nationwide cohort study

Background and Aim: Hepatectomy remains the standard treatment for Barcelona Clinic Liver Cancer (BCLC) stage 0/A hepatocellular carcinoma (HCC). However, debates persist regarding the optimal surgical approach—robot-assisted (RALR), laparoscopic (LLR), or open liver resection (OLR) —due to differences in perioperative outcomes, recurrence patterns, and cost-effectiveness. While minimally invasive techniques offer potential advantages, such as reduced morbidity and faster recovery, their comprehensive impact remains unclear. This study evaluates and compares the intraoperative, postoperative, and economic outcomes of these three approaches in a multicenter cohort of BCLC 0/A HCC patients. Method: Propensity score matching (PSM) was performed to balance baseline characteristics across RALR, LLR, and OLR groups (714 patients each). Intraoperative and postoperative outcomes, as well as long-term recurrence-free survival (RFS) and overall survival (OS), were assessed. Cost-effectiveness was evaluated using quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs). Result: This nationwide retrospective study analyzed 2882 BCLC 0/A HCC patients from 27 centers. After propensity score matching, 2142 patients were analyzed (714 in each group). Operative time was longer in RALR (225 min) and LLR (225 min) compared to OLR (170 min, P < 0. 001). Postoperative complication rates were lower in RALR (12. 5%) and LLR (13. 4%) than in OLR (17. 1%, P < 0. 001), with fewer severe complications (Clavien-Dindo grade ≥ IIIa). The OLR group had a higher proportion of advanced-stage recurrences (BCLC B/C/D: 70. 3%) versus RALR (37. 9%) and LLR (35. 9%) (P < 0. 001). RALR achieved the highest 5-year QALYs (1. 143) among the three groups, while LLR demonstrated superior cost-effectiveness with an ICER of -24, 379/QALY compared to OLR. Conclusion: For BCLC 0/A HCC patients, RALR and LLR demonstrated lower incidence and severity of complications, less advanced-stage recurrence, and higher cost-effectiveness compared to OLR. These findings support the broader adoption of minimally invasive techniques to improve long-term outcomes and quality of life. Despite RALR’s higher initial costs, it remains a highly cost-effective option, offering superior quality of life and long-term economic benefits.