Minimally invasive surgery vs radical open surgery for perihilar cholangiocarcinoma: a systematic review and network meta-analysis

This network meta-analysis (NMA) analyses the latest evidence to evaluate perioperative and postoperative outcomes between minimally invasive surgery (MIS), including robot-assisted (RA) and laparoscopic (LA) approaches, versus open (OA) radical surgery for hilar cholangiocarcinoma (hCCA) and subsequently rank them. A frequentist NMA was performed, and a systematic search of PubMed, Web of Science, Scopus and Cochrane Library databases. This study evaluated 8 perioperative and postoperative outcomes. Pooled relative risk (RR) and standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated using random/fixed-effects models for dichotomous and continuous variables. This NMA analyzed fourteen studies ( n = 1,145). RA achieved R0 resection (P-score = 0.98), lymph node retrieval (P-score = 0.99), intraoperative blood loss (P-score = 0.98), hospital stay (P-score = 0.79). RA and LA ranked similarly in total mortality (P-score = 0.93), LA observed lesser severe morbidities (P-score = 0.90, 95% CI 0.52 to 0.93) and intraoperative blood transfusion (P-score = 0.73). OA boasts the shortest surgical duration. MIS modalities, particularly RA, were associated with comparable oncological outcomes and patient safety compared to OA for hCCA. Our findings acknowledge RA promising but require validation in larger studies. The trade-off is a longer operative time and learning curve. PROSPERO ID: CRD420251109967.