Impact of patient factors on outcomes in robotic major and minor hepatectomy: Importance of patient selection

Impact of patient factors on outcomes in robotic major and minor hepatectomy: Importance of patient selection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of patient factors on outcomes in robotic major and minor hepatectomy: Importance of patient selection Siman Antar, Inara Merani, Mark Hall, Sarah Corn, Ali Ahmad This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8355046/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Jan, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Introduction : Robotic approach to hepatectomy has shown promise in recent times. The aim of our study was to identify the impact of various patient variables on outcomes from robotic major and minor hepatectomy. Methods : Data on 167 consecutive robotic hepatectomy procedures at our institution was retrospectively analyzed. Perioperative outcomes were analyzed for both minor and major hepatectomy. Results : For major hepatectomy (n = 66), factors associated with increased operative time included cirrhosis (301 vs 257min) and obesity (310 vs 261min). Estimated blood loss (EBL) was worse in patients with underlying cirrhosis (242 vs 161 mL), obesity (215 vs 148mL) and tumor size ≥ 10cm (232 vs 136mL). Length of hospital stay (LOS) was also longer with age ≥ 70 years (5.9 vs 4.5 days), cirrhosis (5.6 vs 4.6 days) and malignant tumor pathology (5.1 vs 3.8 days). Similarly, increased postoperative complications were seen with cirrhosis and tumor size ≥ 10cm. For minor hepatectomy (n = 101), operative time was longer in patients with cirrhosis (139 vs 105min), obesity (141 vs 115 min) and posterior-superior (PS) liver resection (168 vs 104 min). Similarly, EBL was higher in cirrhotic patients (163 vs 58mL) and those with PS resection (152 vs 64mL). Longer LOS was observed in elderly patients (2.9 vs 2.0 days), cirrhosis (2.9 vs 2.1 days) and PS resection (2.8 vs 2.1 days). Conclusion : Our study offers a comprehensive understanding of the impact of clinicopathologic factors on outcomes and can be utilized as a guide to appropriate patient selection, especially for surgeons starting a robotic hepatectomy practice. Robotic Hepatectomy Outcomes Liver Perioperative Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 INTRODUCTION The evolution of robotic surgery over the years has allowed complex surgical procedures to be performed in a minimally invasive fashion with encouraging outcomes. Over the past decade, the application of robotic surgical technique has expanded to various fields of surgery including urology, gynecology, thoracic and gastrointestinal surgery. The adoption of minimally invasive approach to complex hepato-pancreatico-biliary (HPB) surgery has traditionally been scarce, primarily owing to technical limitations. However, robotic approach to HPB surgery and in particular hepatic resections has shown promise in recent studies. Robotic hepatectomy has been associated with decreased estimated blood loss (EBL), shorter length of stay (LOS) and therefore decreased morbidity when compared to the traditional open approach [ 1 , 2 ]. When compared to laparoscopy, the robotic platform offers multiple benefits such as enhanced visualization secondary to its 3-dimensional vision and improved dexterity which enhances articulated maneuverability and control. Such benefits can be especially pronounced in HPB surgery where dissection around critical structures and prompt hemorrhage control is integral [ 3 , 4 ]. Although outcomes data on robotic hepatectomy is promising, the specific impact of various factors on such outcomes is still maturing. Various studies have secondarily reflected on such factors which bear a potential influence on peri-operative outcomes [ 5 – 8 ]. Additionally robotic hepatectomy tends to be a diverse entity and outcomes can differ for major (≥ 3 Couinaud segments) and minor hepatectomy (< 3 Couinaud segments). Due to paucity of concrete data, the purpose of our study was to quantitatively define the relationship between patient derived factors and postoperative outcomes in both major and minor robotic hepatic resections. MATERIALS AND METHODS Retrospective chart review was performed on patients undergoing robotic hepatectomy at our institution between 2017 and 2022. A total of 167 patients were identified, of whom 101 underwent minor hepatectomy and 66 underwent major hepatectomy. Approval was obtained from the institutional review board (IRB) for this study. Major hepatectomy was defined as resection of 3 or more contiguous hepatic Couinaud segments. As per widely accepted definition, posterior-superior segments were defined as anatomic hepatic Couinaud segments 4a, 7 and 8. Demographic and clinic-pathological factors included age, sex, body mass index (BMI), cirrhosis, and American Society of Anesthesiologists (ASA) classification (Table 1 ). Pathology reports were analyzed to determine tumor size, number of tumors and resection margin status. Per standard definition, obesity was defined as body mass index (BMI) ≥ 30 kg/m 2 . Cirrhosis was defined as presence of Child-Pugh class A and B cirrhosis. There were no patients with Child-Pugh class C cirrhosis patients in the study. Table 1 Demographics and Tumor Characteristics Minor Hepatectomy Major Hepatectomy Patients (n) 101 66 Age (years) 60.6 (17–87) 59.7 (30–88) Sex • Male 40 (40%) 35 (53%) • Female 61 (60%) 31 (47%) BMI (Mean) 28.7 (19–54) 27.9 (18–55) ASA (Mean) 3 3 Cirrhosis 14 (14%) 7 (11%) Mean Tumor size (cm) 4.6 (1–15) 7.6 (3–18) Pathology • Pre-malignant/Benign 26 (26%) 16 (24%) • Malignant 75 (74%) 50 (76%) Our study focused on the following outcomes: operative time, EBL, LOS, tumor margins (R0 vs R1), 30-day readmission rate, mortality rates and overall complications. We utilized Clavien-Dindo grade 3 and 4 to define clinically significant complications. Entire data was assembled from the institutional electronic medical records. Statistical analysis was performed using Microsoft Excel ® (Microsoft Corporation, Redmond, WA), MedCalc ® (MD Aware LLC, New York, NY) and SPSS® for windows (SPSS Inc, Chicago, IL). Qualitative and quantitative analysis between groups was performed using chi-square test and student’s t-test respectively. Odds ratios (OR) were utilized to define quantitative relationships between mixed variables. Statistical significance was defined as P < 0.05 with reported 95% confidence intervals. Multivariate regression models were generated to analyze independent associations between various factors and defined outcomes. We also identified concomitant procedures that were simultaneously performed at the time of hepatectomies. Statistical analysis was reported separately for these procedures to define the impact of multi-visceral resections on robotic hepatectomy outcomes. RESULTS Demographics: A total of 167 patients were included in this study. Minor hepatectomy was performed on 101 patients (60%) whereas 66 patients (40%) underwent robotic major hepatectomy (Table 1 ). Among the 101 patients who underwent minor hepatectomy, forty (40%) were male and 61 patients (60%) were female. The mean age in this group was 60.6 years and mean BMI was 28.7 kg/m2. Fourteen patients (14%) had underlying liver cirrhosis and malignant disease was present in 75 patients (74%). The mean tumor size was 4.6 cm in this group. Within the 66 patients who underwent major hepatectomy, 35 (53%) were male and 31 (47%) were female. The mean age in this group was 59.7 years and mean BMI was 27.9 kg/m2. Seven patients (11%) had underlying liver cirrhosis and malignant disease was present in 50 patients (76%). The mean tumor size among these patients was 7.6 cm. Outcomes Minor Hepatectomy: In the group who underwent minor hepatectomy (Table 2 ), the average operative time was 128 minutes, and the mean EBL was 84mL. The mean length of stay (LOS) among these patients was 2.3 days (0–7 days). Overall complication rate (Clavien-Dindo grade 3/4) was 3% (Table 3 ). Table 2 Clinical Outcomes Minor Hepatectomy Major Hepatectomy Operative Time (mins) 128 (55–390) 271 (130–655) Estimated blood loss (mL) 84 (15–600) 170 (40–700) Tumor Margins • Negative (R0) 98 (97%) 64 (97%) • Positive (R1) 3 (3%) 2 (3%) Length of stay (days) 2.3 (0–7) 4.7 (2–12) Complications 2 (2%) 6 (9%) Death 1 (1%) 1 (2%) 30-day Readmission 1 (1%) 2 (3%) Table 3 Complications Complications* Extent of Hepatectomy Minor 3 (3%) Major 6 (9%) Bile leak 2 (2%) 3 (5%) Liver failure 0 1 (2%) Atrial fibrillation 1 (1%) 1 (2%) Renal failure 0 1 (2%) * Clavien-Dindo Grade 3/4 1. Operative Time : Operative time (Fig. 1 ) was longer in patients with underlying cirrhosis (139 vs 105 mins, p = 0.048). It was also adversely affected by patients with obesity (141 vs 115 mins, p = 0.032) as well as patients undergoing resection of posterior-superior (PS) segments (168 vs 104 mins, p = 0.001). 2. Estimated Blood Loss (EBL) : The presence of underlying liver cirrhosis was associated with higher EBL (Fig. 2 ) when compared to non-cirrhotic patients (163mL vs 58mL, p = 0.041). Similarly, resection of PS segments was associated with increased operative EBL (152mL vs 64mL, p < 0.001). There was no association observed between EBL and obesity or other variables in this group. 3. Lenth of Hospital Stay (LOS) : The LOS (Fig. 3 ) was higher in elderly patients with age ≥ 70 years (2.9 vs 2.0 days, p = 0.019). Additionally, patients with PS segment resection had increased LOS at 2.8 vs 2.1 days (p = 0.027) as well as patients with cirrhosis (2.9 vs 2.1 days, p = 0.049). No differences were observed in overall complication rate, 30-day readmission rate or mortality among the various previously defined variables in robotic minor hepatectomy. Major Hepatectomy Among the robotic major hepatectomy group (Table 2 ), the average duration of surgery was 271 mins and mean EBL was 170mL. The overall complication rate was 9% in this group (Table 3 ). The average length of stay in this group was 4.7 days (2–12 days). 1. Operative Time : Mean operative time (Fig. 4 ) was adversely affected by the presence of cirrhosis (301 vs 257 mins, p = 0.036). Similar to minor hepatectomy, obese patients had a longer mean operative time of 310 mins vs 261 mins (p = 0.022). 2. Estimated Blood Loss (EBL) : Operative EBL (Fig. 5 ) was worse in patients with cirrhosis (242mL vs 161mL, p = 0.028), obesity (215mL vs 148ml, p = 0.031) and in patients with the size of largest tumor ≥ 10cm (232mL vs 136mL, p = 0.001). 3. Length of Hospital Stay (LOS) : Elderly patients were found to have a longer mean LOS at 5.9 days vs 4.5 days (p = 0.036). Other factors associated with longer LOS (Fig. 6 ) included presence of cirrhosis (5.6 vs 4.6 days, p = 0.045) and malignant tumor pathology (5.1 vs 3.8 days, p = 0.029). 4. Overall Complication Rate : Unlike minor hepatectomy, a higher complication rate in major hepatectomy was associated with several factors (Fig. 7 ) including cirrhosis (OR 3.53 [1.51–18.34], p = 0.018) and largest tumor size ≥ 10cm (OR 3.13 [1.37–8.44], p = 0.024) On multivariate analysis, these factors remained independently associated with worse overall complication rate; cirrhosis (p = 0.028) and tumor size ≥ 10cm (p = 0.011). Among the patients who underwent major robotic hepatectomy, no association was found between the various studied variables and mortality or 30-day readmission rate. Concomitant procedures: Six patients (6%) in the minor hepatectomy group and 4 patients (6%) in the major hepatectomy group had concomitant procedures performed simultaneously with the hepatectomy procedure (Table 4 ). For minor hepatectomy, such additional procedures were associated with increased operative time (230 vs 122mins, p < 0.001), EBL (105mL vs 62mL) and longer LOS (4.4 vs 2.1 days, p = 0.002). In the major hepatectomy group, addition of concomitant procedures was associated with longer operative time (358 vs 262 mins, p = 0.011), higher EBL (275mL vs 159mL, p = 0.037), longer LOS (8.1 vs 4.4 days, p < 0.001) and a higher overall complication rate (OR 8.41 [2.67–18.55], p = 0.011). Table 4 Concomitant Procedures Concomitant Procedures Extent of Hepatectomy Minor 6 (6%) Major 4 (6%) Right hemicolectomy 2 (2%) 1 (2%) Low anterior resection 2 (2%) 0 Distal pancreatectomy 1 (1%) 0 Small bowel resection 1 (1%) 1 (2%) Ileostomy reversal 0 1 (2%) Nephrectomy 0 1 (2%) DISCUSSION Robotic surgery has gained significant popularity in recent times, owing to its numerous advantages and better short-term outcomes when compared to a variety of open or laparoscopic procedures [ 9 , 10 ]. Robotic approach offers several technical advantages because of its 3-dimentional visualization, articulated multi-joint arms for improved flexibility and control, integrated use of ultrasound and shorter learning curve [ 11 , 12 ]. Safety and efficacy of robotic surgery has been established through multiple studies [ 13 , 14 ]. Minimally invasive hepatectomy through a robotic approach has also been incorporated into practice because of its safety, feasibility, lower conversion rate and fewer complications when compared with open hepatectomy [ 15 , 16 ]. Although the efficacy of robotic hepatectomy has been established, the predictive relationship between various independent patient derived factors and perioperative or short-term outcomes is challenging to determine. Clinical factors such as patient demographics, disease pathology and tumor characteristics are all potential contributing factors that can alter surgical outcomes. Elderly patients are substantially more susceptible to the morbidity of complex procedures. In line with previously published studies, we used age ≥ 70 years as a cutoff to define the elderly population [ 16 , 17 ]. Robotic approach has shown promise in minimizing morbidity in this subset of patients [ 17 , 18 ]. Zhang et al showed a decreased overall complication rate in elderly patients undergoing robotic hepatectomy when compared to the traditional open approach [ 19 ]. Our study supports such favorable outcomes of the robotic approach in the elderly. Additionally, both robotic major and minor hepatectomy can be safely performed in elderly patients with similar complication rate, mortality, and overall morbidity when compared to younger patients. In our study, the only parameter adversely affected by age was the length of hospital stay, with a mean LOS difference of 0.9 days in minor hepatectomy and 1.4 days in major hepatectomy group. Elderly patients usually require more assistance in the immediate post-op care owing to the increased difficulty with early ambulation, pulmonary exercise, and compromised nutrition. However, despite those challenges, the LOS difference is substantially less pronounced when compared to data from open hepatectomy series [ 20 , 21 ]. In recent years, particularly in developed countries such as the United States, there has been a notable increase in the population with higher body mass index (BMI) [ 22 ]. Increased BMI is associated with higher complication rates in surgeries, including those performed with robotic assistance [ 23 – 24 ]. However, Lin et al. demonstrated superiority of the robotic approach when compared to open hepatectomy in patients with high BMI, with lower operative time, EBL, and postoperative complications [ 25 ]. Our study found that obesity was linked to prolonged operative times in both major and minor hepatectomy procedures, with a significant increase in EBL during major hepatectomy. However, outcomes such as hospital LOS, complication rate, readmission rate and mortality remain unaffected. In our experience, robotic hepatectomy can be safely performed in obese patients, which is in line with previously published series by Sucandy et al. [ 26 ]. Obesity increases the technical complexity of most hepatectomy procedures similar to other abdominal surgeries, primarily owing to the presence of increased visceral fat. In addition to the obscured visualization, hepatic parenchymal architecture can be altered ranging from non-alcoholic fatty liver disease (NAFLD) to non-alcoholic steatohepatitis (NASH) and cirrhosis. These can potentially pose substantial challenges for surgeons early in their learning curve. Large tumor size and the location of lesions especially in the posterior and superior segments of the liver (Couinaud segments IVa, VII, and VIII) have long been recognized as important prognostic elements in hepatic resections, primarily due to increased technical difficulty, prolonged operative times, and higher EBL [ 28 , 29 ]. Liu et al. demonstrated superiority of the robotic approach over traditional laparoscopic hepatectomy especially for larger tumors [ 30 ]. In our study, we found that tumor size greater than 10 cm was associated with increased EBL as well as a higher overall complication rate in major hepatectomies. In our experience, resection of the PS segments was associated with increased operative time and EBL in minor hepatectomies. Compared to laparoscopy, Krenzien et al. demonstrated superior perioperative outcomes, evident by reduced operative time and EBL with robotic approach to PS segmental resections [ 31 ]. Although PS hepatic resections are technically challenging, we believe the robotic platform offers technical advantages to safely execute these procedures with excellent outcomes. Presence of liver cirrhosis complicates the hepatectomy procedure by adversely affecting both intraoperative conditions as well as postoperative recovery [ 32 ]. In our analysis, cirrhosis was associated with worse perioperative outcomes, particularly in terms of operative time and EBL, across both major and minor hepatectomy groups. Other studies have also addressed the impact of cirrhosis on robotic and laparoscopic approaches, demonstrating similar negative effects on EBL and operative time [ 33 , 34 ]. We found that the presence of cirrhosis was also associated with increased LOS and overall complication rate. Various studies have also demonstrated that patients with cirrhosis undergoing minimally invasive hepatectomies had higher post-operative morbidity [ 32 – 34 ]. Despite these challenges, robotic hepatectomy remains a preferred approach for cirrhotic patients. Chen et al. found that robotic hepatectomy for hepatocellular carcinoma in cirrhotic patients resulted in shorter LOS when compared to open hepatectomy [ 35 ]. In line with previously published results, our findings support the safety of robotic approach to hepatectomy, even in the presence of cirrhosis [ 36 ]. The relationship between various clinico-pathological factors and outcomes in robotic hepatectomy is multi-faceted. Additionally, the extent and type of hepatectomy can alter outcomes due to the variability in complexity of hepatectomy procedures. Multi-visceral resections, such as concomitant colorectal resections, can be safely performed via the robotic approach, however, these are associated with increased operative time, EBL, LOS and complication rate. In our opinion, such procedures should only be undertaken in highly selected patients along with appropriate robotic expertise. In the modern era of increasing interest in robotic hepatectomy, it should be stressed that robotic hepatectomy, in itself, is a complex procedure and caution should be exercised when deciding on simultaneous concomitant procedures. Emphasis should be placed on appropriate patient selection, especially early on. We have previously published our experience of robotic hepatectomy learning curves, both for major and minor liver resections [ 37 ]. Based on our current study, patients with underlying cirrhosis, morbid obesity, patients with larger tumors > 10cm in size or with tumors located within the posterior-superior liver segments have worse outcomes and may be best reserved for when surgical proficiency in performing robotic hepatectomy is attained. Our study may serve as a guide to understanding the relationship of robotic hepatectomy outcomes to patient derived factors, which in turn could help with appropriate patient selection for both robotic major and minor hepatectomy, especially for surgeons early in their learning curve. The limitation of our study is that it is a single center study. We believe that further studies at multiple centers and larger populations will be necessary to further explore the impact of clinicopathologic factors on long term outcomes. In conclusion, this study re-affirms the safety and viability of robotic major and minor hepatectomy. Results from our study offer a comprehensive understanding of the impact of various clinicopathologic factors on outcomes and can be utilized as a guide to appropriate patient selection, especially for surgeons starting a robotic hepatectomy practice. Declarations Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest Statement: Dr. Ali Ahmad has received honoraria for teaching didactic courses and proctoring other surgeons by Intuitive Surgical, USA. Other authors have no relevant financial disclosures. ACKNOWLEDGEMTNTS: None DISCLOSURES: Ali Ahmad has received honoraria for teaching didactic courses and proctoring other surgeons by Intuitive Surgical, USA. Siman Antar has no conflict of interest Inara Merani has no conflict of interest Mark G Hall has no conflict of interest. Sarah D Corn has no conflict of interest. References Gavriilidis P, Roberts KJ, Aldrighetti L, Sutcliffe RP (2020) A comparison between robotic, laparoscopic and open hepatectomy: a systematic review and network meta-analysis. 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Ali Ahmad has received honoraria for teaching didactic courses and proctoring other surgeons by Intuitive Surgical, USA. Cite Share Download PDF Status: Published Journal Publication published 14 Jan, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 23 Dec, 2025 Reviews received at journal 23 Dec, 2025 Reviewers agreed at journal 23 Dec, 2025 Reviews received at journal 22 Dec, 2025 Reviewers agreed at journal 22 Dec, 2025 Reviewers agreed at journal 18 Dec, 2025 Reviewers invited by journal 16 Dec, 2025 Editor assigned by journal 15 Dec, 2025 Submission checks completed at journal 14 Dec, 2025 First submitted to journal 13 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8355046","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":561847517,"identity":"d977883f-dfd9-43cf-a6e0-ef6f7c4cb809","order_by":0,"name":"Siman Antar","email":"","orcid":"","institution":"University of Kansas-Wichita","correspondingAuthor":false,"prefix":"","firstName":"Siman","middleName":"","lastName":"Antar","suffix":""},{"id":561847518,"identity":"a9018166-d71e-46d9-8692-f7d87733df33","order_by":1,"name":"Inara Merani","email":"","orcid":"","institution":"University of 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2","display":"","copyAsset":false,"role":"figure","size":844995,"visible":true,"origin":"","legend":"\u003cp\u003eFactors impacting EBL in Robotic Minor Hepatectomy\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8355046/v1/ec493f96a17f04adc6a18a68.png"},{"id":98779873,"identity":"f3a1d352-fcff-47c6-9275-dfe3e629ccaf","added_by":"auto","created_at":"2025-12-22 12:30:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":855604,"visible":true,"origin":"","legend":"\u003cp\u003eFactors impacting LOS in Robotic Minor Hepatectomy\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8355046/v1/7a78acc966486a3d214a3c50.png"},{"id":98780571,"identity":"7ab69325-9ead-4d85-8f7c-1361541b6076","added_by":"auto","created_at":"2025-12-22 12:31:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":973425,"visible":true,"origin":"","legend":"\u003cp\u003eFactors impacting Operative Time in Robotic Major Hepatectomy\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-8355046/v1/297123a9fcef790c61e019f2.png"},{"id":98779069,"identity":"8defc5ea-533a-4274-9113-b02b6d1da5ff","added_by":"auto","created_at":"2025-12-22 12:29:56","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":916734,"visible":true,"origin":"","legend":"\u003cp\u003eFactors impacting EBL in Robotic Major Hepatectomy\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-8355046/v1/20ccd8ba01492bf2870ce1b2.png"},{"id":98778582,"identity":"25edc51b-cef2-43d1-883a-4b09ef8932a9","added_by":"auto","created_at":"2025-12-22 12:29:27","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":915164,"visible":true,"origin":"","legend":"\u003cp\u003eFactors Impacting LOS in Robotic Major Hepatectomy\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-8355046/v1/7a17390ae797e5b2c0c5f167.png"},{"id":98777713,"identity":"5f019310-718c-4f74-be2c-96e2b067d845","added_by":"auto","created_at":"2025-12-22 12:28:23","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":758571,"visible":true,"origin":"","legend":"\u003cp\u003eOdds Ratios (OR) of Complications\u003c/p\u003e","description":"","filename":"Figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-8355046/v1/9b4134a8ef8530011b77c24a.png"},{"id":100614642,"identity":"c8441327-0b05-45f8-b916-4613662f2909","added_by":"auto","created_at":"2026-01-19 17:22:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6791267,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8355046/v1/b061f1b0-bfa6-4a80-90c1-8c14c643eb78.pdf"}],"financialInterests":"Competing interest reported. Ali Ahmad has received honoraria for teaching didactic courses and proctoring other surgeons by Intuitive Surgical, USA.","formattedTitle":"Impact of patient factors on outcomes in robotic major and minor hepatectomy: Importance of patient selection","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe evolution of robotic surgery over the years has allowed complex surgical procedures to be performed in a minimally invasive fashion with encouraging outcomes. Over the past decade, the application of robotic surgical technique has expanded to various fields of surgery including urology, gynecology, thoracic and gastrointestinal surgery.\u003c/p\u003e \u003cp\u003eThe adoption of minimally invasive approach to complex hepato-pancreatico-biliary (HPB) surgery has traditionally been scarce, primarily owing to technical limitations. However, robotic approach to HPB surgery and in particular hepatic resections has shown promise in recent studies. Robotic hepatectomy has been associated with decreased estimated blood loss (EBL), shorter length of stay (LOS) and therefore decreased morbidity when compared to the traditional open approach [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. When compared to laparoscopy, the robotic platform offers multiple benefits such as enhanced visualization secondary to its 3-dimensional vision and improved dexterity which enhances articulated maneuverability and control. Such benefits can be especially pronounced in HPB surgery where dissection around critical structures and prompt hemorrhage control is integral [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough outcomes data on robotic hepatectomy is promising, the specific impact of various factors on such outcomes is still maturing. Various studies have secondarily reflected on such factors which bear a potential influence on peri-operative outcomes [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Additionally robotic hepatectomy tends to be a diverse entity and outcomes can differ for major (\u0026ge;\u0026thinsp;3 Couinaud segments) and minor hepatectomy (\u0026lt;\u0026thinsp;3 Couinaud segments). Due to paucity of concrete data, the purpose of our study was to quantitatively define the relationship between patient derived factors and postoperative outcomes in both major and minor robotic hepatic resections.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e Retrospective chart review was performed on patients undergoing robotic hepatectomy at our institution between 2017 and 2022. A total of 167 patients were identified, of whom 101 underwent minor hepatectomy and 66 underwent major hepatectomy. Approval was obtained from the institutional review board (IRB) for this study. Major hepatectomy was defined as resection of 3 or more contiguous hepatic Couinaud segments. As per widely accepted definition, posterior-superior segments were defined as anatomic hepatic Couinaud segments 4a, 7 and 8. Demographic and clinic-pathological factors included age, sex, body mass index (BMI), cirrhosis, and American Society of Anesthesiologists (ASA) classification (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Pathology reports were analyzed to determine tumor size, number of tumors and resection margin status. Per standard definition, obesity was defined as body mass index (BMI)\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e. Cirrhosis was defined as presence of Child-Pugh class A and B cirrhosis. There were no patients with Child-Pugh class C cirrhosis patients in the study.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics and Tumor Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinor Hepatectomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMajor Hepatectomy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.6 (17\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.7 (30\u0026ndash;88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (53%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (47%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (Mean)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.7 (19\u0026ndash;54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.9 (18\u0026ndash;55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA (Mean)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCirrhosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Tumor size (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.6 (1\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6 (3\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Pre-malignant/Benign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (24%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Malignant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (76%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOur study focused on the following outcomes: operative time, EBL, LOS, tumor margins (R0 vs R1), 30-day readmission rate, mortality rates and overall complications. We utilized Clavien-Dindo grade 3 and 4 to define clinically significant complications. Entire data was assembled from the institutional electronic medical records. Statistical analysis was performed using Microsoft Excel \u0026reg; (Microsoft Corporation, Redmond, WA), MedCalc \u0026reg; (MD Aware LLC, New York, NY) and SPSS\u0026reg; for windows (SPSS Inc, Chicago, IL). Qualitative and quantitative analysis between groups was performed using chi-square test and student\u0026rsquo;s t-test respectively. Odds ratios (OR) were utilized to define quantitative relationships between mixed variables. Statistical significance was defined as P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 with reported 95% confidence intervals. Multivariate regression models were generated to analyze independent associations between various factors and defined outcomes.\u003c/p\u003e \u003cp\u003eWe also identified concomitant procedures that were simultaneously performed at the time of hepatectomies. Statistical analysis was reported separately for these procedures to define the impact of multi-visceral resections on robotic hepatectomy outcomes.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDemographics:\u003c/h2\u003e \u003cp\u003eA total of 167 patients were included in this study. Minor hepatectomy was performed on 101 patients (60%) whereas 66 patients (40%) underwent robotic major hepatectomy (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong the 101 patients who underwent minor hepatectomy, forty (40%) were male and 61 patients (60%) were female. The mean age in this group was 60.6 years and mean BMI was 28.7 kg/m2. Fourteen patients (14%) had underlying liver cirrhosis and malignant disease was present in 75 patients (74%). The mean tumor size was 4.6 cm in this group.\u003c/p\u003e \u003cp\u003eWithin the 66 patients who underwent major hepatectomy, 35 (53%) were male and 31 (47%) were female. The mean age in this group was 59.7 years and mean BMI was 27.9 kg/m2. Seven patients (11%) had underlying liver cirrhosis and malignant disease was present in 50 patients (76%). The mean tumor size among these patients was 7.6 cm.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMinor Hepatectomy:\u003c/h2\u003e \u003cp\u003eIn the group who underwent minor hepatectomy (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e), the average operative time was 128 minutes, and the mean EBL was 84mL. The mean length of stay (LOS) among these patients was 2.3 days (0\u0026ndash;7 days). Overall complication rate (Clavien-Dindo grade 3/4) was 3% (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical Outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinor\u003c/p\u003e \u003cp\u003eHepatectomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMajor\u003c/p\u003e \u003cp\u003eHepatectomy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative Time (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128 (55\u0026ndash;390)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e271 (130\u0026ndash;655)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated blood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84 (15\u0026ndash;600)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e170 (40\u0026ndash;700)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Margins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Negative (R0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (97%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (97%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Positive (R1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.3 (0\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.7 (2\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-day Readmission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eExtent of Hepatectomy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinor\u003c/p\u003e \u003cp\u003e3 (3%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMajor\u003c/p\u003e \u003cp\u003e6 (9%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBile leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* Clavien-Dindo Grade 3/4\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e1. Operative Time\u003c/em\u003e:\u003c/p\u003e \u003cp\u003eOperative time (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) was longer in patients with underlying cirrhosis (139 vs 105 mins, p\u0026thinsp;=\u0026thinsp;0.048). It was also adversely affected by patients with obesity (141 vs 115 mins, p\u0026thinsp;=\u0026thinsp;0.032) as well as patients undergoing resection of posterior-superior (PS) segments (168 vs 104 mins, p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e2. Estimated Blood Loss (EBL)\u003c/em\u003e:\u003c/p\u003e \u003cp\u003eThe presence of underlying liver cirrhosis was associated with higher EBL (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) when compared to non-cirrhotic patients (163mL vs 58mL, p\u0026thinsp;=\u0026thinsp;0.041). Similarly, resection of PS segments was associated with increased operative EBL (152mL vs 64mL, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no association observed between EBL and obesity or other variables in this group.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e3. Lenth of Hospital Stay (LOS)\u003c/em\u003e:\u003c/p\u003e \u003cp\u003eThe LOS (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) was higher in elderly patients with age\u0026thinsp;\u0026ge;\u0026thinsp;70 years (2.9 vs 2.0 days, p\u0026thinsp;=\u0026thinsp;0.019). Additionally, patients with PS segment resection had increased LOS at 2.8 vs 2.1 days (p\u0026thinsp;=\u0026thinsp;0.027) as well as patients with cirrhosis (2.9 vs 2.1 days, p\u0026thinsp;=\u0026thinsp;0.049).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNo differences were observed in overall complication rate, 30-day readmission rate or mortality among the various previously defined variables in robotic minor hepatectomy.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMajor Hepatectomy\u003c/h3\u003e\n\u003cp\u003eAmong the robotic major hepatectomy group (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e), the average duration of surgery was 271 mins and mean EBL was 170mL. The overall complication rate was 9% in this group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The average length of stay in this group was 4.7 days (2\u0026ndash;12 days).\u003c/p\u003e \u003cp\u003e \u003cem\u003e1. Operative Time\u003c/em\u003e:\u003c/p\u003e \u003cp\u003eMean operative time (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) was adversely affected by the presence of cirrhosis (301 vs 257 mins, p\u0026thinsp;=\u0026thinsp;0.036). Similar to minor hepatectomy, obese patients had a longer mean operative time of 310 mins vs 261 mins (p\u0026thinsp;=\u0026thinsp;0.022).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e2. Estimated Blood Loss (EBL)\u003c/em\u003e:\u003c/p\u003e \u003cp\u003eOperative EBL (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) was worse in patients with cirrhosis (242mL vs 161mL, p\u0026thinsp;=\u0026thinsp;0.028), obesity (215mL vs 148ml, p\u0026thinsp;=\u0026thinsp;0.031) and in patients with the size of largest tumor\u0026thinsp;\u0026ge;\u0026thinsp;10cm (232mL vs 136mL, p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e3. Length of Hospital Stay (LOS)\u003c/em\u003e:\u003c/p\u003e \u003cp\u003eElderly patients were found to have a longer mean LOS at 5.9 days vs 4.5 days (p\u0026thinsp;=\u0026thinsp;0.036). Other factors associated with longer LOS (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) included presence of cirrhosis (5.6 vs 4.6 days, p\u0026thinsp;=\u0026thinsp;0.045) and malignant tumor pathology (5.1 vs 3.8 days, p\u0026thinsp;=\u0026thinsp;0.029).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e4. Overall Complication Rate\u003c/em\u003e:\u003c/p\u003e \u003cp\u003eUnlike minor hepatectomy, a higher complication rate in major hepatectomy was associated with several factors (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e) including cirrhosis (OR 3.53 [1.51\u0026ndash;18.34], p\u0026thinsp;=\u0026thinsp;0.018) and largest tumor size\u0026thinsp;\u0026ge;\u0026thinsp;10cm (OR 3.13 [1.37\u0026ndash;8.44], p\u0026thinsp;=\u0026thinsp;0.024) On multivariate analysis, these factors remained independently associated with worse overall complication rate; cirrhosis (p\u0026thinsp;=\u0026thinsp;0.028) and tumor size\u0026thinsp;\u0026ge;\u0026thinsp;10cm (p\u0026thinsp;=\u0026thinsp;0.011).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAmong the patients who underwent major robotic hepatectomy, no association was found between the various studied variables and mortality or 30-day readmission rate.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eConcomitant procedures:\u003c/h2\u003e \u003cp\u003eSix patients (6%) in the minor hepatectomy group and 4 patients (6%) in the major hepatectomy group had concomitant procedures performed simultaneously with the hepatectomy procedure (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). For minor hepatectomy, such additional procedures were associated with increased operative time (230 vs 122mins, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), EBL (105mL vs 62mL) and longer LOS (4.4 vs 2.1 days, p\u0026thinsp;=\u0026thinsp;0.002). In the major hepatectomy group, addition of concomitant procedures was associated with longer operative time (358 vs 262 mins, p\u0026thinsp;=\u0026thinsp;0.011), higher EBL (275mL vs 159mL, p\u0026thinsp;=\u0026thinsp;0.037), longer LOS (8.1 vs 4.4 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a higher overall complication rate (OR 8.41 [2.67\u0026ndash;18.55], p\u0026thinsp;=\u0026thinsp;0.011).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConcomitant Procedures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcomitant Procedures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eExtent of Hepatectomy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinor\u003c/p\u003e \u003cp\u003e6 (6%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMajor\u003c/p\u003e \u003cp\u003e4 (6%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight hemicolectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow anterior resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal pancreatectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall bowel resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleostomy reversal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNephrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eRobotic surgery has gained significant popularity in recent times, owing to its numerous advantages and better short-term outcomes when compared to a variety of open or laparoscopic procedures [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Robotic approach offers several technical advantages because of its 3-dimentional visualization, articulated multi-joint arms for improved flexibility and control, integrated use of ultrasound and shorter learning curve [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Safety and efficacy of robotic surgery has been established through multiple studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Minimally invasive hepatectomy through a robotic approach has also been incorporated into practice because of its safety, feasibility, lower conversion rate and fewer complications when compared with open hepatectomy [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the efficacy of robotic hepatectomy has been established, the predictive relationship between various independent patient derived factors and perioperative or short-term outcomes is challenging to determine. Clinical factors such as patient demographics, disease pathology and tumor characteristics are all potential contributing factors that can alter surgical outcomes.\u003c/p\u003e \u003cp\u003eElderly patients are substantially more susceptible to the morbidity of complex procedures. In line with previously published studies, we used age\u0026thinsp;\u0026ge;\u0026thinsp;70 years as a cutoff to define the elderly population [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Robotic approach has shown promise in minimizing morbidity in this subset of patients [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Zhang et al showed a decreased overall complication rate in elderly patients undergoing robotic hepatectomy when compared to the traditional open approach [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Our study supports such favorable outcomes of the robotic approach in the elderly. Additionally, both robotic major and minor hepatectomy can be safely performed in elderly patients with similar complication rate, mortality, and overall morbidity when compared to younger patients. In our study, the only parameter adversely affected by age was the length of hospital stay, with a mean LOS difference of 0.9 days in minor hepatectomy and 1.4 days in major hepatectomy group. Elderly patients usually require more assistance in the immediate post-op care owing to the increased difficulty with early ambulation, pulmonary exercise, and compromised nutrition. However, despite those challenges, the LOS difference is substantially less pronounced when compared to data from open hepatectomy series [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, particularly in developed countries such as the United States, there has been a notable increase in the population with higher body mass index (BMI) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Increased BMI is associated with higher complication rates in surgeries, including those performed with robotic assistance [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, Lin et al. demonstrated superiority of the robotic approach when compared to open hepatectomy in patients with high BMI, with lower operative time, EBL, and postoperative complications [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Our study found that obesity was linked to prolonged operative times in both major and minor hepatectomy procedures, with a significant increase in EBL during major hepatectomy. However, outcomes such as hospital LOS, complication rate, readmission rate and mortality remain unaffected. In our experience, robotic hepatectomy can be safely performed in obese patients, which is in line with previously published series by Sucandy et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Obesity increases the technical complexity of most hepatectomy procedures similar to other abdominal surgeries, primarily owing to the presence of increased visceral fat. In addition to the obscured visualization, hepatic parenchymal architecture can be altered ranging from non-alcoholic fatty liver disease (NAFLD) to non-alcoholic steatohepatitis (NASH) and cirrhosis. These can potentially pose substantial challenges for surgeons early in their learning curve.\u003c/p\u003e \u003cp\u003eLarge tumor size and the location of lesions especially in the posterior and superior segments of the liver (Couinaud segments IVa, VII, and VIII) have long been recognized as important prognostic elements in hepatic resections, primarily due to increased technical difficulty, prolonged operative times, and higher EBL [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Liu et al. demonstrated superiority of the robotic approach over traditional laparoscopic hepatectomy especially for larger tumors [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In our study, we found that tumor size greater than 10 cm was associated with increased EBL as well as a higher overall complication rate in major hepatectomies. In our experience, resection of the PS segments was associated with increased operative time and EBL in minor hepatectomies. Compared to laparoscopy, Krenzien et al. demonstrated superior perioperative outcomes, evident by reduced operative time and EBL with robotic approach to PS segmental resections [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Although PS hepatic resections are technically challenging, we believe the robotic platform offers technical advantages to safely execute these procedures with excellent outcomes.\u003c/p\u003e \u003cp\u003ePresence of liver cirrhosis complicates the hepatectomy procedure by adversely affecting both intraoperative conditions as well as postoperative recovery [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In our analysis, cirrhosis was associated with worse perioperative outcomes, particularly in terms of operative time and EBL, across both major and minor hepatectomy groups. Other studies have also addressed the impact of cirrhosis on robotic and laparoscopic approaches, demonstrating similar negative effects on EBL and operative time [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. We found that the presence of cirrhosis was also associated with increased LOS and overall complication rate. Various studies have also demonstrated that patients with cirrhosis undergoing minimally invasive hepatectomies had higher post-operative morbidity [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Despite these challenges, robotic hepatectomy remains a preferred approach for cirrhotic patients. Chen et al. found that robotic hepatectomy for hepatocellular carcinoma in cirrhotic patients resulted in shorter LOS when compared to open hepatectomy [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In line with previously published results, our findings support the safety of robotic approach to hepatectomy, even in the presence of cirrhosis [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe relationship between various clinico-pathological factors and outcomes in robotic hepatectomy is multi-faceted. Additionally, the extent and type of hepatectomy can alter outcomes due to the variability in complexity of hepatectomy procedures. Multi-visceral resections, such as concomitant colorectal resections, can be safely performed via the robotic approach, however, these are associated with increased operative time, EBL, LOS and complication rate. In our opinion, such procedures should only be undertaken in highly selected patients along with appropriate robotic expertise. In the modern era of increasing interest in robotic hepatectomy, it should be stressed that robotic hepatectomy, in itself, is a complex procedure and caution should be exercised when deciding on simultaneous concomitant procedures. Emphasis should be placed on appropriate patient selection, especially early on. We have previously published our experience of robotic hepatectomy learning curves, both for major and minor liver resections [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Based on our current study, patients with underlying cirrhosis, morbid obesity, patients with larger tumors\u0026thinsp;\u0026gt;\u0026thinsp;10cm in size or with tumors located within the posterior-superior liver segments have worse outcomes and may be best reserved for when surgical proficiency in performing robotic hepatectomy is attained. Our study may serve as a guide to understanding the relationship of robotic hepatectomy outcomes to patient derived factors, which in turn could help with appropriate patient selection for both robotic major and minor hepatectomy, especially for surgeons early in their learning curve.\u003c/p\u003e \u003cp\u003eThe limitation of our study is that it is a single center study. We believe that further studies at multiple centers and larger populations will be necessary to further explore the impact of clinicopathologic factors on long term outcomes.\u003c/p\u003e \u003cp\u003eIn conclusion, this study re-affirms the safety and viability of robotic major and minor hepatectomy. Results from our study offer a comprehensive understanding of the impact of various clinicopathologic factors on outcomes and can be utilized as a guide to appropriate patient selection, especially for surgeons starting a robotic hepatectomy practice.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement:\u003c/strong\u003e Dr. Ali Ahmad has received honoraria for teaching didactic courses and proctoring other surgeons by Intuitive Surgical, USA. Other authors have no relevant financial disclosures.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMTNTS:\u003c/strong\u003e None\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDISCLOSURES:\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eAli Ahmad has received honoraria for teaching didactic courses and proctoring other surgeons by Intuitive Surgical, USA.\u003c/li\u003e\n \u003cli\u003eSiman Antar has no conflict of interest\u003c/li\u003e\n \u003cli\u003eInara Merani has no conflict of interest\u003c/li\u003e\n \u003cli\u003eMark G Hall has no conflict of interest.\u003c/li\u003e\n \u003cli\u003eSarah D Corn has no conflict of interest.\u003c/li\u003e\n\u003c/ol\u003e\n\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGavriilidis P, Roberts KJ, Aldrighetti L, Sutcliffe RP (2020) A comparison between robotic, laparoscopic and open hepatectomy: a systematic review and network meta-analysis. Eur J Surg Oncol 46(7):1214\u0026ndash;1224\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen PD, Wu CY, Hu RH, Chou WH, Lai HS, Liang JT, Lee PH, Wu YM (2017) Robotic versus open hepatectomy for hepatocellular carcinoma: a matched comparison. Ann Surg Oncol 24:1021\u0026ndash;1028\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCai JP, Chen W, Chen LH, Wan XY, Lai JM, Yin XY (2022) Comparison between robotic-assisted and laparoscopic left hemi-hepatectomy. Asian J Surg 45(1):265\u0026ndash;268\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiang JT, Lai HS (2014) Surgical technique of robotic D3 lymph node dissection around the inferior mesenteric artery with preservation of the left colic artery and autonomic nerves for the treatment of distal rectal cancer. Surg Endosc 28:1727\u0026ndash;1733\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathur AK, Ghaferi AA, Sell K, Sonnenday CJ, Englesbe MJ, Welling TH (2010) Influence of body mass index on complications and oncologic outcomes following hepatectomy for malignancy. J Gastrointest Surg 14(5):858\u0026ndash;866\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkamura Y, Maeda A, Matsunaga K, Kanemoto H, Uesaka K (2012) Negative impact of low body mass index on surgical outcomes after hepatectomy for hepatocellular carcinoma. J Hepato-Biliary‐Pancreatic Sci 19(4):449\u0026ndash;457\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWakai T, Shirai Y, Sakata J, Korita PV, Ajioka Y, Hatakeyama K (2011) Surgical outcomes for hepatocellular carcinoma in nonalcoholic fatty liver disease. J Gastrointest Surg 15(8):1450\u0026ndash;1458\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Meijer VE, Kalish BT, Puder M, IJzermans JNM (2010) Systematic review and meta-analysis of steatosis as a risk factor in major hepatic resection. J Br Surg 97(9):1331\u0026ndash;1339\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKasai S, Kagawa H, Shiomi A, Hino H, Manabe S, Yamaoka Y, Kato S, Hanaoka M, Kinugasa Y (2022) Advantages of robotic abdominoperineal resection compared with laparoscopic surgery: a single-center retrospective study. Surg Today 52(4):643\u0026ndash;651\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMasetti M, Fallani G, Ratti F, Ferrero A, Giuliante F, Cillo U, Guglielmi A, Ettorre GM, Torzilli G, Vincenti L, Ercolani G (2022) Minimally invasive treatment of colorectal liver metastases: does robotic surgery provide any technical advantages over laparoscopy? A multicenter analysis from the IGoMILS (Italian Group of Minimally Invasive Liver Surgery) registry. Updates Surg 74(2):535\u0026ndash;545\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026oacute;mez Ruiz M, Lainez Escribano M, Cagigas Fernandez C, Poch C, L. and, Martinez S, S (2020) Robotic surgery for colorectal cancer. Annals Gastroenterological Surg 4(6):646\u0026ndash;651\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong SW, Ang ZH, Yang PF, Crowe P (2022) Robotic colorectal surgery and ergonomics. J Robotic Surg, pp.1\u0026ndash;6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDwyer RH, Scheidt MJ, Marshall JS, Tsoraides SS (2018) Safety and efficacy of synchronous robotic surgery for colorectal cancer with liver metastases. J robotic Surg 12(4):603\u0026ndash;606\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSucandy I, Schlosser S, Bourdeau T, Spence J, Attili A, Ross S, Rosemurgy A (2020) Robotic hepatectomy for benign and malignant liver tumors. J Robotic Surg 14:75\u0026ndash;80\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu Y, Guo K, Xu J, Xia T, Wang T, Liu N, Fu Y (2021) Robotic versus laparoscopic hepatectomy for malignancy: a systematic review and meta-analysis. Asian J Surg 44(4):615\u0026ndash;628\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuchs NC, Addeo P, Bianco FM, Ayloo S, Elli EF, Giulianotti PC (2010) Safety of robotic general surgery in elderly patients. J robotic Surg 4:91\u0026ndash;98\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSucandy I, Luberice K, Rivera-Espineira G, Krill E, Castro M, Bourdeau T, Ross S, Rosemurgy A (2021) Robotic major hepatectomy: influence of age on clinical outcomes\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTee MC, Chen L, Peightal D, Franko J, Kim PT, Brahmbhatt RD, Raman S, Scudamore CH, Chung SW, Segedi M (2020) Minimally invasive hepatectomy is associated with decreased morbidity and resource utilization in the elderly, vol 34. Surgical endoscopy, pp 5030\u0026ndash;5040\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang XP, Xu S, Hu MG, Zhao ZM, Wang ZH, Zhao GD, Li CG, Tan XL, Liu R (2022) Short-and long-term outcomes after robotic and open liver resection for elderly patients with hepatocellular carcinoma: a propensity score-matched study. Surg Endosc 36(11):8132\u0026ndash;8143\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVallance AE, Young AL, Kuryba A, Braun M, Hill J, Jayne DG, van der Meulen J, Lodge JP, Walker K (2019) The impact of advancing age on incidence of hepatectomy and post-operative outcomes in patients with colorectal cancer liver metastases: a population-based cohort study. HPB 21(2):167\u0026ndash;174\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReddy SK, Barbas AS, Turley RS, Gamblin TC, Geller DA, Marsh JW, Tsung A, Clary BM, Lagoo-Deenadayalan S (2011) Major liver resection in elderly patients: a multi-institutional analysis. J Am Coll Surg 212(5):787\u0026ndash;795\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJanssen F, Bardoutsos A, Vidra N (2020) Obesity prevalence in the long-term future in 18 European countries and in the USA. Obes Facts 13(5):514\u0026ndash;527\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRi M, Aikou S, Seto Y (2018) Obesity as a surgical risk factor. Annals gastroenterological Surg 2(1):13\u0026ndash;21\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun YD, Zhang H, Chen YQ, Wu CX, Chen ML, Xu HR, Wang S, Liu JZ, Han JJ (2021) Overweight with HBV infection limited the efficacy of TACE in hepatocellular carcinoma by inhibiting the upregulated HMGB1. BMC Cancer 21:1\u0026ndash;17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin ZY, Zhang XP, Zhao GD, Li CG, Wang ZH, Liu R, Hu MG (2023) Short-term outcomes of robotic versus open hepatectomy among overweight patients with hepatocellular carcinoma: a propensity score-matched study. BMC surgery, 23(1), p.153\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSucandy I, Attili A, Spence J, Bordeau T, Ross S, Rosemurgy A (2020) The impact of body mass index on perioperative outcomes after robotic liver resection. J Robotic Surg 14:41\u0026ndash;46\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFruscione M, Pickens R, Baker EH, Cochran A, Khan A, Ocuin L, Iannitti DA, Vrochides D, Martinie JB (2019) Robotic-assisted versus laparoscopic major liver resection: analysis of outcomes from a single center. Hpb 21(7):906\u0026ndash;911\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShehta A, Elsabbagh AM, Medhat M, Farouk A, Monier A, Said R, Salah T, Elshobari M, Fouad A, Elghawalby AN (2024) Impact of tumor size on the outcomes of hepatic resection for hepatocellular carcinoma: a retrospective study. BMC Surg 24(1):7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawaguchi Y, Fuks D, Kokudo N, Gayet B (2018) Difficulty of laparoscopic liver resection: proposal for a new classification. Ann Surg 267(1):13\u0026ndash;17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Q, Zhang W, Zhao JJ, Syn NL, Cipriani F, Alzoubi M, Aghayan DL, Siow TF, Lim C, Scatton O, Herman P (2023) Propensity-score matched and coarsened-exact matched analysis comparing robotic and laparoscopic major hepatectomies: an international multicenter study of 4822 cases. Ann Surg 278(6):969\u0026ndash;975\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrenzien F, Schmelzle M, Pratschke J, Feldbr\u0026uuml;gge L, Liu R, Liu Q, Zhang W, Zhao JJ, Tan HL, Cipriani F, Hoogteijling TJ (2024) Propensity score-matching analysis comparing robotic versus laparoscopic limited liver resections of the posterosuperior segments: an international multicenter study. Ann Surg 279(2):297\u0026ndash;305\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSong S, Wang Z, Liu K, Zhang X, Zhang G, Zeng G, Zhu L, Yao Z, Hu M, Wang Z, Liu R (2024) Perioperative impact of liver cirrhosis on robotic liver resection for hepatocellular carcinoma: a retrospective cohort study. Surg Endosc 38(9):4926\u0026ndash;4938\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCipriani F, Aldrighetti L, Ratti F, Wu AG, Kabir T, Scatton O, Lim C, Zhang W, Sijberden J, Aghayan DL, Siow TF (2024) Impact of Liver Cirrhosis, Severity of Cirrhosis, and Portal Hypertension on the Difficulty and Outcomes of Laparoscopic and Robotic Major Liver Resections for Primary Liver Malignancies. Ann Surg Oncol 31(1):97\u0026ndash;114\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoh BK, Syn N, Lee SY, Koh YX, Teo JY, Kam JH, Cheow PC, Jeyaraj PR, Chow PK, Ooi LL, Chung AY (2021) Impact of liver cirrhosis on the difficulty of minimally-invasive liver resections: a 1: 1 coarsened exact-matched controlled study. Surg Endosc 35:5231\u0026ndash;5238\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen PD, Wu CY, Hu RH, Chou WH, Lai HS, Liang JT, Lee PH, Wu YM (2017) Robotic versus open hepatectomy for hepatocellular carcinoma: a matched comparison. Ann Surg Oncol 24:1021\u0026ndash;1028\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Benedetto F, Magistri P, Di Sandro S, Sposito C, Oberkofler C, Brandon E, Samstein B, Guidetti C, Papageorgiou A, Frassoni S, Bagnardi V (2023) Safety and efficacy of robotic vs open liver resection for hepatocellular carcinoma. JAMA Surg 158(1):46\u0026ndash;54\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmad A, Freeman HD, Corn SD (2023) Robotic major and minor hepatectomy: critical appraisal of learning curve and its impact on outcomes. Surg Endosc 37(4):2915\u0026ndash;2922\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Robotic, Hepatectomy, Outcomes, Liver, Perioperative","lastPublishedDoi":"10.21203/rs.3.rs-8355046/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8355046/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eIntroduction\u003c/b\u003e: Robotic approach to hepatectomy has shown promise in recent times. The aim of our study was to identify the impact of various patient variables on outcomes from robotic major and minor hepatectomy.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e: Data on 167 consecutive robotic hepatectomy procedures at our institution was retrospectively analyzed. Perioperative outcomes were analyzed for both minor and major hepatectomy.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e: For major hepatectomy (n\u0026thinsp;=\u0026thinsp;66), factors associated with increased operative time included cirrhosis (301 vs 257min) and obesity (310 vs 261min). Estimated blood loss (EBL) was worse in patients with underlying cirrhosis (242 vs 161 mL), obesity (215 vs 148mL) and tumor size\u0026thinsp;\u0026ge;\u0026thinsp;10cm (232 vs 136mL). Length of hospital stay (LOS) was also longer with age\u0026thinsp;\u0026ge;\u0026thinsp;70 years (5.9 vs 4.5 days), cirrhosis (5.6 vs 4.6 days) and malignant tumor pathology (5.1 vs 3.8 days). Similarly, increased postoperative complications were seen with cirrhosis and tumor size\u0026thinsp;\u0026ge;\u0026thinsp;10cm.\u003c/p\u003e \u003cp\u003eFor minor hepatectomy (n\u0026thinsp;=\u0026thinsp;101), operative time was longer in patients with cirrhosis (139 vs 105min), obesity (141 vs 115 min) and posterior-superior (PS) liver resection (168 vs 104 min). Similarly, EBL was higher in cirrhotic patients (163 vs 58mL) and those with PS resection (152 vs 64mL). Longer LOS was observed in elderly patients (2.9 vs 2.0 days), cirrhosis (2.9 vs 2.1 days) and PS resection (2.8 vs 2.1 days).\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e: Our study offers a comprehensive understanding of the impact of clinicopathologic factors on outcomes and can be utilized as a guide to appropriate patient selection, especially for surgeons starting a robotic hepatectomy practice.\u003c/p\u003e","manuscriptTitle":"Impact of patient factors on outcomes in robotic major and minor hepatectomy: Importance of patient selection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 09:48:12","doi":"10.21203/rs.3.rs-8355046/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-23T11:28:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-23T10:59:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"114507466563649904528650605504542431092","date":"2025-12-23T07:43:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T20:18:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82283355653074326641466394261117024517","date":"2025-12-22T12:38:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115986741073859814544439501200565741823","date":"2025-12-18T22:22:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-16T12:08:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-16T02:07:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-15T02:36:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2025-12-13T21:30:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"ab1457d9-37fe-4b7e-aaaa-e85155d0a5a8","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T16:46:53+00:00","versionOfRecord":{"articleIdentity":"rs-8355046","link":"https://doi.org/10.1007/s11701-026-03152-8","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2026-01-14 16:28:56","publishedOnDateReadable":"January 14th, 2026"},"versionCreatedAt":"2025-12-22 09:48:12","video":"","vorDoi":"10.1007/s11701-026-03152-8","vorDoiUrl":"https://doi.org/10.1007/s11701-026-03152-8","workflowStages":[]},"version":"v1","identity":"rs-8355046","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8355046","identity":"rs-8355046","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}