Measuring success in hepatectomy

Advancements in liver resectionHistorically, operating on the liver has been a precarious endeavor due to its vascularity and complex anatomy.The high mortality rate associated with liver surgery in its early stages rendered it risky.In 1886, the first partial hepatectomy was attempted by Antonio Lius, but resulted in fatal postoperative hemorrhage (1).In 1887, Dr. Langenbuch performed the first successful liver resection, although reoperation was required due to hemorrhage (1).The earliest estimates of morbidity and mortality for hepatectomy were bleak.In 1963, Dr. Brunschwig reported a 29% mortality rate for right and left lobe resections (2).It was not until the 1970s-1980s that advancements in technology and immunosuppressants allowed for acceptable outcomes (3).With improvements in surgical tools, antibiotics, and general anesthesia, recent data for liver resection yield a postoperative morbidity of 19.6-37% and 90-day mortality of 3-5.4% (4-7). Open, laparoscopic, and robotic hepatectomyMorbidity rates continue to improve as we move away from open surgery in favor of minimally invasive approaches.This holds true in hepatectomy.Gavriilidis et al. conducted a meta-analysis of 79 studies comparing robotic, laparoscopic, and open hepatectomy (8).Both robotic and laparoscopic cohorts had lower estimated blood loss (EBL), shorter length of stay (LOS), and less Clavien-Dindo III-IV grade morbidity compared to the open cohort.The robotic cohort had longer "operative time" and "duration of clamping" compared to both laparoscopic and open cohorts.Five-year overall survival was better in the robotic and laparoscopic cohorts compared to the open cohort.Differences in 1, 3, and 5-year disease free survival as well as overall survival at 1 and 3 years were nonsignificant.Results vary in comparisons between robotic and laparoscopic hepatectomy.However, a more recent study analyzing posterosuperior liver resection showed that robotic resection had shorter operative time (160 vs. 208 min, P=0.001), shorter Pringle maneuver duration (40 vs. 51 min, P=0.047), lower EBL (92 vs. 150 mL, P=0.005), and shorter postoperative hospital stay (5.4 vs. 7.5 days, P=0.048) (9).In propensity score matched analysis, robotic resection had reduced operative time (P=0.036)and lower EBL (P=0.024)than laparoscopic resection.Although the differences between robotic and laparoscopic surgery generally have been unclear, outcomes may become more apparent over time as familiarity, training, and technology in robotic systems improve. Surgical outcome indicators Mortality rates for liver resection in hepatocellular