Nationwide cohort study of robotic, laparoscopic, and open liver resection for hepatocellular carcinoma—a propensity score overlap weighted study

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Abstract Introduction Minimally invasive liver surgery for hepatocellular carcinoma (HCC) is increasing. Data comparing robotic-assisted liver surgery (RALS) to laparoscopic liver surgery (LLS) for HCC remain limited. This study aimed to compare short-term and survival outcomes, following national adoption of RALS in Sweden, compared with laparoscopic (LLS) and open liver surgery (OLS). Methods Patients undergoing liver resection for HCC in Sweden between 2019‒2023 were identified in the Swedish National Quality Registry for Liver, Gallbladder and Bile Duct Cancer (SweLiv). Multiple imputation was used to handle missing data. Pairwise propensity score overlap weighting was applied to balance baseline characteristics for RALS, LLS, and OLS. Short-term outcomes were analysed using weighted logistic and linear regression models, and overall survival (OS) using weighted Cox regression. Results In total, 450 patients were included, 57 RALS, 102 LLS and 291 OLS. RALS and LLS were associated with reduced intraoperative blood loss compared with OLS (150 ml versus 400 ml, P < 0.001 and 300 ml versus 400 ml, P = 0.001, respectively). No differences were observed between RALS and LLS. Overall survival was similar across the surgical approaches, (RALS versus LLS HR 0.9, P = 0.823, RALS versus OLS HR 0.80, P = 0.538, and LLS versus OLS HR 0.72, P = 0.224). Discussion In this nationwide cohort, robotic and laparoscopic liver resections for HCC were associated with comparable perioperative and oncologic outcomes. Minimally invasive approaches reduced intraoperative blood loss compared with open surgery, without compromising short-term safety or survival. Surgical approach should primarily be guided by tumour characteristics, liver function, and local expertise.

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