Liver Robotic Surgery. A Review of Current Use and Future Perspectives

Robotic liver surgery is increasingly being recognized as the next step in minimally invasive procedures and is currently undergoing significant advancement. Its technology represents the most advanced form of minimally invasive surgery, though there are still some unresolved challenges regarding its implementation in clinical practice (28). The robotic system provides a stable visual platform, eliminates physiological tremors, enhances surgical precision, and offers better ergonomics through a seated operating position (1). Given these potential benefits, robotic assistance may be particularly well-suited for complex liver procedures, which require delicate tissue handling, highly accurate intracorporeal suturing, and intricate parenchymal dissection—followed by the need for meticulous bleeding and bile leak control. Parenchymal transection remains one of the most technically demanding aspects (2). Robotic hepatectomy is commonly used to treat liver tumors. For patients with large (≥ 5 cm) hepatocellular carcinoma, robotic hepatectomy has been shown to be a safe and feasible option. Giulianotti et al. first reported robotic-assisted laparoscopic hepatectomy (28). Since then, medical centers around the world have shared their experiences with this technique (29). The lack of specialized instruments and the development of various techniques have so far prevented the establishment of a standardized surgical approach. Nowadays, the increasing use of ICG-fluorescence imaging in patients undergoing minimally invasive resections for colorectal liver metastases, aiming to improve radical resection rates and the accuracy of tumor margin identification. At the same time colorectal cancer (CRC) remains one of the primary causes of cancer-related mortality, with liver metastases occurring in approximately 25–30% of patients (3). The presence of metastatic disease in the liver places a considerable burden on the healthcare system, not only by driving up costs and expenditures but also by increasing the need for and use of medical resources (4). Robot-assisted simultaneous colon and liver resections are becoming increasingly common as the use of robotic platforms grows in the surgical treatment of metastatic colon cancer. Nevertheless, this technique remains underexplored, with current evidence limited to case series. In this paper we focus on an overview of the recent advances in the surgical, robotic treatment of colorectal liver metastasis (CRLM).

A total of 14 studies that included patients who underwent RLR (robotic liver resections) in patients with CRLM were considered eligible for inclusion in our narrative review. Four of them were single case reports, one was a literature systematic review, one multicentric prospective and the others all monocentric studies (5 retrospective and 3 prospective). Four of them originated from Italy, two from the United States, two from Deutschland, one from Belgium, one from China, one from India, one from Brasil, one from Korea and one from Nederland. The indices analyzed were tabulated in Table 1.

The global incidence of CRC has been rising with annual increases of 3.2%, beginning with 783,000 cases in 1999 and increasing to 1.8 million in 2020 (5). Colorectal cancer (CRC) is the third most common malignancy and the second most common cause of cancer-related mortality worldwide

Colorectal cancer (CRC) is among the most common causes of cancer-related mortality, with liver metastases occurring in roughly 25–30% of diagnosed individuals. Around 15% of patients were found to have liver metastases at the time of diagnosis, and nearly half of all individuals with colorectal cancer are expected to develop liver metastases at some point during their lives (6).Earlier studies indicate a variation in survival outcomes between patients with liver metastases originating from right-sided versus left-sided CRC, despite the fact that left-sided tumors tend to develop liver metastases more frequently (3).

The development of liver metastases from colorectal cancer is a prolonged and intricate process. It encompasses the persistence of the primary tumor, invasion into blood vessels, distant spread, and the eventual formation of metastases. The establishment of a supportive microenvironment prior to metastasis significantly facilitates tumor colonization and growth. During the progression of liver metastases in colorectal cancer, these events do not occur in a strict sequence but often happen simultaneously. The liver, which receives blood from the gastrointestinal tract, is the most common site for colorectal cancer to spread. It contains various resident cell types that contribute to the formation of a pre-metastatic niche. Some of these cells aid in tumor attachment and colonization, others support tumor cell growth, modulate the immune environment, or promote the formation of new blood vessels (7). Interventional oncology plays a key role in managing liver metastases from colorectal cancer by expanding the pool of patients eligible for surgery, offering potentially curative options to those who cannot undergo surgery, and enhancing survival outcomes in palliative care scenarios. While surgical removal remains the preferred approach when feasible, image-guided ablation—either alone or combined with surgery—has shown better survival outcomes compared to chemotherapy by itself. Selecting appropriate candidates—particularly those with tumors smaller than 3 cm—and ensuring ablation margins exceed 5 mm can help reduce local tumor recurrence. Techniques like cryoablation may be effective in alleviating symptoms caused by painful lesions, while irreversible electroporation (IRE) offers a non-thermal option for tumors located near sensitive structures, such as bile ducts, where heat-based treatments are less suitable due to the heat sink effect. As treatment strategies continue to shift, more research is needed, particularly given the rising incidence of colorectal cancer in younger individuals (8). When examining surgical options, robotic techniques have seen significant advancements. Laparoscopic surgery is now widely regarded as the standard approach for specific procedures, such as left-lateral sectionectomies and wedge resections of anterior liver segments. However, the exact role of robotic liver surgery remains under discussion, particularly in terms of long-term cancer-related outcomes. Robotic technology represents the most advanced form of minimally invasive surgery, though there are still some unresolved challenges regarding its implementation in clinical practice. Robot-assisted, minimally invasive surgery has already become a reality and is likely to be the future standard for many procedures. Conventional laparoscopy has several limitations, such as restricted movement, difficulty performing precise sutures, awkward surgeon positioning, and a lack of 3D visualization. Robotic surgery addresses many of these challenges and broadens the potential for minimally invasive surgery to benefit more patients (28). Robotic surgery presents as a compelling minimally invasive alternative for liver procedures due to enhanced visualization and the use of highly articulated instruments (9). Challenges such as longer operative times and the absence of tactile sensation have been noted, although these drawbacks have not been clearly demonstrated in clinical studies. On the other hand, according to Machado et al., robotic repeat hepatectomy is a viable and safe option when performed by skilled surgeons and may offer certain benefits compared to laparoscopic or open repeat liver resections (17). Unique aspects of robotic procedures, including specific safety measures, must be established and reviewed at the start of each operation to prepare for possible emergency conversions. Although many liver surgeons have been slow to adopt this technique, robotic liver surgery continues to develop and gain acceptance in the field. Current data indicate that cancer outcomes following robotic liver resections are comparable to those seen with open or laparoscopic techniques for both hepatocellular carcinoma and colorectal liver metastases, with additional benefits noted in cirrhotic patients and those requiring repeat operations (10). Achieving optimal outcomes and maintaining high levels of patient safety requires targeted training in both hepatobiliary and general minimally invasive surgical skills to successfully navigate the learning curve. As we can infer from our review experience, the age of patients varies greatly, reaching up to 88 years, demonstrating a relatively wide application of robotic surgery. The site most commonly associated with metastatic issues is the rectum, and the robot performs particularly well in minor hepatic resections. However, there is limited long-term data, although the encouraging results motivate us to increasingly use this surgical approach in the future. Many of the studies reviewed evaluated the feasibility of robotic-assisted surgery for the treatment of colorectal liver metastases (CRLM), highlighting its beneficial role even in patients with multiple metastases or those who had undergone previous or simultaneous surgeries. Emerging imaging technologies (11) such as near-infrared (NIR) fluorescence with indocyanine green (ICG) may help offset the absence of tactile sensation in minimally invasive surgery and act as a valuable complement to intraoperative ultrasound (IOUS). Many laparoscopic and robotic platforms currently in clinical use are either compatible with or already integrated with NIR fluorescence imaging capabilities. The use of ICG fluorescence can offer surgeons real-time visualization of tumor boundaries during minimally invasive procedures for colorectal liver metastases, potentially enhancing the rate of complete oncologic resections. Achterberg et al have shown that ICG-guided imaging is linked to a higher frequency of margin-negative resections and led to intraoperative strategy modifications in over 25% of cases. Notably, the lack of ICG signal in the liver during parenchymal dissection was found to predict an R0 resection with 92% precision (12). These findings indicate that ICG fluorescence can support intraoperative decision-making and improve oncologic outcomes by providing accurate, real-time delineation of tumor margins.A limitation of our work is certainly the number of reviewed papers; however, few papers focused on the strictly surgical and robotic aspects.Future prospects are definitely the continued advancements that are anticipated in both resection techniques and diagnostic tools. Technologies such as artificial intelligence—which is already being implemented in laparoscopy — augmented reality, intraoperative navigation, and hybrid operating rooms are expected to play an increasingly important role. These innovations support surgeons in managing complex anatomies that are not visible on the surface and often exhibit significant individual variation.

As research progresses and new weapons are available for the treatment of CRLM , surgery maintains its predominant role. Robotic liver surgery is now a consolidated reality. Its application in the treatment of liver metastases from colorectal cancer is the future. This minimally invasive approach proposes treatment of the pathology either concurrently or subsequently to the primary surgery with encouraging outcomes. Robotic combined resection for colorectal cancer with liver metastases is technically achievable and appears to offer comparable oncologic outcomes to those of open or laparoscopic procedures . Further studies are necessary in the future to reinforce our conclusions considering the relatively small number of involved papers.