Precision-Guided Surgery for Hilar Cholangiocarcinoma: A Network Meta-Analysis of Robotic, Laparoscopic, and Open Resection

Background: Open hilar resection has long been the standard for hilar cholangiocarcinoma (HCCA) due to the complex biliary anatomy, but its invasiveness remains a concern. We conducted a network meta-analysis to evaluate whether minimally invasive approaches, particularly robotic hilar resection, can improve perioperative outcomes without compromising oncological results. Methods: We performed a Bayesian network meta-analysis of 18 studies involving 2,216 patients. Due to limited reporting, formal subgroup network estimates were not feasible. Primary outcomes included estimated blood loss, R0 resection rate, and Clavien-Dindo grade ≥ III complications. Results: We included 18 studies reporting data on 2,216 patients in a Bayesian network meta-analysis. Robotic resection ranked highest for reducing estimated blood loss (SUCRA 89%). Open surgery remained the fastest (mean difference −84.2 min, 95% CrI −112 to −56.4), while robotic resection showed comparable R0 rates to open surgery (OR 1.04, 95% CrI 0.82–1.31). Major complications were similar across approaches. Trends favoring robotics appeared more pronounced in complex (Bismuth III/IV) tumors, although dedicated subgroup analyses were limited by available data. Conclusion: The optimal surgical approach for hilar cholangiocarcinoma should be individualized according to anatomical complexity, patient condition, and institutional expertise. In experienced centers, robotic resection offers a viable precisionv guided option that improves certain perioperative outcomes without apparent oncological detriment.