Evidence - Right Hemihepatectomy, Robotically Assisted

Preface

Until the 1980s, operative mortality following liver resections was approximately 20%, primarily due to significant intraoperative bleeding [1]. Advances in liver anatomy understanding, safer anesthesia, and improved perioperative care made liver surgery safer, leading to the increased popularity of minimally invasive techniques in the mid-1990s. In recent years, robotic techniques have gained prominence worldwide, particularly in hepatobiliary and complex oncological surgery.

Surgical Therapy for Primary Liver Tumors – Resection and Transplantation

The two most common malignant primary liver tumors are:

• Hepatocellular carcinoma (HCC)
• Intrahepatic cholangiocarcinoma (iCCC)
• Hepatocellular Carcinoma (HCC)
• HCC is a primary liver tumor with hepatocytic differentiation originating from hepatocytes at various stages of differentiation [2]
• In Germany, there are approximately 8,300 new cases annually, with a similar number of deaths
• The average age of onset is 70 years in men and 74 years in women [2]
• Globally, HCC remains among the top ten causes of cancer mortality due to its poor prognosis [4]

Intrahepatic Cholangiocarcinoma (iCCC)

• iCCC is a malignancy with biliary differentiation, originating in the intrahepatic bile ducts [3]
• iCCC represents approximately 5 – 10% of all primary liver malignancies, with considerable geographic variation
• High-incidence regions include Asia due to endemic infections with liver flukes (Opisthorchis viverrini and Clonorchis sinensis)
• In low-incidence regions such as the United States, the incidence is 1–2 cases per 100,000 inhabitants, comparable to rates in Germany
• The average age of onset is 55 years, and men are more frequently affected. The incidence of iCCC continues to rise [2]

Surgical Therapy for iCCC

• iCCCs often remain asymptomatic for a prolonged period and are frequently diagnosed at an advanced stage [5, 6, 7]
• Types of iCCC:
  • Periductal-infiltrating and intraductal-growing (rare)
  • Often cause biliary obstruction (jaundice)
• Mass-forming type (most common):
  • Presents as a large, solitary or multifocal tumor with potential infiltration of major blood vessels
  • Jaundice is uncommon and typically results from compression of the hepatic bifurcation or, rarely, direct tumor infiltration [5, 6, 9, 10]

Radical Surgical Resection:

• The only curative treatment for iCCC remains complete surgical resection (R0).
• Since iCCCs often arise in non-cirrhotic livers, extended resections are often feasible.
• 5-year survival rates post-R0 resection range between 21 – 45 % across all tumor stages [6, 7, 10–13].

Prognostic Factors:

• Negative outcomes are associated with:
  • Distant metastasis
  • Multifocal disease
  • Lymph node metastases
  • Vascular invasion [7, 10, 13–15]

Multimodal Therapy Concepts

Surgical therapy for iCCC is increasingly integrated into multimodal treatment strategies:

 1. Adjuvant Therapy:

• The BILCAP study demonstrated a median survival of 53 months with surgery plus adjuvant capecitabine therapy compared to 36 months with surgery alone [16]
• Capecitabine is now considered the standard adjuvant therapy

  2. Neoadjuvant Therapy:

• In a French multicenter analysis, initially unresectable or borderline-resectable iCCCs achieved comparable outcomes to primarily resectable tumors following secondary resection
• Results were significantly better compared to systemic chemotherapy alone [12]

   3.  R1 Resection and Chemotherapy:

• Studies suggest that R1 resections combined with chemotherapy provide superior survival outcomes compared to chemotherapy alone [6, 7, 11, 17]

   4. Palliative Resection:

• Debulking (R2 resection) is rarely indicated and should only be considered in selected cases

Recurrent iCCC

• Isolated intrahepatic recurrences occur in approximately 50 % of patients within 2 years post-resection.
• Emerging therapies:
• Local ablative treatments or repeat surgical resection have achieved outcomes comparable to primary resection [11, 18].
• Liver Transplantation for iCCC
• Currently has limited relevance for iCCC.
• In patients with very early-stage iCCC (solitary tumor < 2 cm), 5-year survival rates of up to 65 % have been reported [19].
• The German Federal Medical Guidelines recommend liver transplantation for iCCC only within clinical trials [20].

Conclusion

Advances in liver surgery and multimodal treatment approaches have significantly improved the prognosis for iCCC. Radical surgical resection remains the cornerstone of curative treatment, supported by adjuvant and, increasingly, neoadjuvant therapies. In well-selected cases, repeat resection or local therapies for recurrent disease have shown promising outcomes. Liver transplantation remains experimental, reserved for very early-stage cases within clinical trial settings.

Surgical Therapy for HCC

Hepatocellular carcinoma (HCC) develops in over 85 % of cases in a cirrhotic liver. The presence and degree of cirrhosis, as well as its underlying etiology, are critical for diagnosis, therapy, and prognosis .

Both the currently revised German HCC guidelines and the European guidelines recommend liver transplantation (LTX) as the treatment of choice for HCC in cirrhosis . LTX is contraindicated in cases of extrahepatic tumor manifestations or radiologically detectable infiltration of major hepatic vessels 

For patients with compensated liver function, resection is an alternative to transplantation. However, extensive resections are rarely feasible due to the limited functional reserve of the cirrhotic liver. Moreover, resections in cirrhosis carry a heightened perioperative risk, particularly exacerbated by portal hypertension. Studies suggest that morbidity can be reduced through a laparoscopic approach . Analyses report 5-year survival rates after resection of small, solitary HCCs ranging between 30 % and 55 %, and up to over 75 % in highly selected subgroups .

Despite the curative potential of resection, the recurrence risk within five years is between 60% and 80 %, as resection treats only the HCC lesion but not the underlying disease (hence the recommendation for LTX). Effective adjuvant therapy following R0 resection for HCC in cirrhosis is largely unavailable, and there is currently no solid evidence for neoadjuvant therapies . Recurrences after HCC resection in cirrhosis are often confined to the liver, allowing for individualized repeat resections or LTX. Reported 5-year survival rates are approximately 60 % for repeat resections and up to 80 % for salvage LTX.

In non-cirrhotic livers, resection remains the treatment of choice for HCC. In stage M1, resection is generally not indicated, though isolated lung or adrenal metastases may be exceptions. Following R0 resection of HCC in non-cirrhotic livers, 5-year survival rates between 26% and 60% have been described .

Despite potentially curative resection, tumor recurrence occurs in over half of patients within the first two years. Most recurrences are multifocal intrahepatic or combined intra- and extrahepatic. Isolated intrahepatic recurrences that are amenable to resection are rare. In cases of irresectable locally advanced tumors or tumor recurrences, LTX may also be considered for HCC in non-cirrhotic livers. A European multicenter analysis involving over 100 patients reported 5-year survival of 49% and disease-free survival of 43% after LTX in these cases .

The updated German HCC guidelines, alongside the European guidelines, recommend liver transplantation (LTX) as the treatment of choice for HCC in patients with cirrhosis. However, LTX is contraindicated in cases of extrahepatic tumor dissemination or radiologically evident invasion of major hepatic vessels.

Therapy of Metastatic Colorectal Cancer

In the past, the goal of therapy for patients with stage IV colorectal cancer was exclusively palliative. However, in recent years, prognosis has significantly improved even in stage IV disease due to both more aggressive surgical approaches and systemic tumor therapy (combinations of doublet chemotherapy and targeted antibodies). It has become evident that up to 25% of patients with synchronous hepatic metastases from colorectal cancer have curative potential. The 5-year survival rate can reach up to 50%, significantly improving prognosis for approximately 20% of patients with metastatic disease.

Literature reports response rates of up to 60% through the use of various chemotherapy protocols. Curative potential also exists for patients with hepatic recurrence or isolated pulmonary metastases. The disease-free survival rate for patients with resectable liver or lung metastases is up to 50% at 5 years. The criterion for technical resectability of metastases is achieving an R0 resection.

The indication for and optimal regimens of perioperative systemic therapy remain under discussion. Treatment decisions are made on a case-by-case basis, taking tumor biology into account, and should always be evaluated in an interdisciplinary tumor board. Whenever possible, treatment within the context of a clinical trial should be considered.

For systemic therapy in patients with resectable liver metastases, perioperative treatment with FOLFOX (3 months preoperatively and 3 months postoperatively) can be employed, based on data from the Phase III EORTC 40983 Intergroup Trial. However, data supporting the use of targeted therapies in the setting of resectable metastases are currently lacking. In fact, Cetuximab worsened outcomes in this context. Perioperative FOLFOX should primarily be offered to patients with higher-risk profiles or those in whom a “biological window” to observe tumor biology has been deemed appropriate following interdisciplinary discussion.

If perioperative chemotherapy is not administered, systemic therapy can be offered postoperatively, again preferentially with a fluoropyrimidine and oxaliplatin. In patients with low recurrence risk following metastasis resection, adjuvant or “secondary adjuvant” chemotherapy may be omitted, as its overall effect on survival outcomes is limited. Recent data from a randomized Japanese study showed improved progression-free survival with 6 months of FOLFOX therapy but no benefit in overall survival.

Resection of metastases remains a central component of the curative approach. The following criteria should be met for surgical intervention:

• Absence of non-resectable extrahepatic metastases
• 30 % functional residual liver tissue postoperatively
• Adequate safety margins relative to critical hepatic vessels
• No hepatic insufficiency, no Child B or C liver cirrhosis
• ECOG performance status 0 – 2
• Absence of severe comorbidities

Decisions regarding the resectability of liver metastases must always be made in interdisciplinary tumor board discussions.

(Refer also to the evidence chapter on robotic rectal resection at www.webop.de)

Technical Aspects of Liver Surgery

In resections for primary liver tumors, all technical possibilities in liver surgery are utilized while taking the functional residual liver capacity into account【6, 7, 9, 10, 11, 13】. In a healthy liver, up to 80% of the liver volume can be resected.

For hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCC) in non-cirrhotic livers, the standard procedure is anatomical liver resection. In addition to classical (extended) hemihepatectomies, smaller tumors may also be treated with segmentectomies and less common techniques such as sectorectomies or mesohepatectomies【6–13】. The primary goal is R0 resection with an appropriate safety margin, although no solid evidence exists regarding the optimal margin size. 

Before resection, the liver can be conditioned to increase the functional liver remnant (FLR), achieving hypertrophy rates of up to 40%. Standard techniques include portal vein embolization, with portal vein ligation being used less frequently【29】. The “in-situ split” or “associating liver partition and portal vein ligation for staged hepatectomy” (ALPPS) can achieve FLR volume increases of 60% to over 100% within a week. However, due to its significant perioperative complication rate, ALPPS is performed very cautiously【31】.

In addition to extensive liver resections, vascular resections and bile duct resections are often required, especially in iCCC【6, 7, 9, 13, 32, 33】. When a curative approach seems achievable, these technical extensions are no longer considered contraindications, although they are associated with a notable perioperative mortality rate of up to 10%.

For HCC in cirrhosis, smaller resections and segmentectomies are predominantly performed, while hemihepatectomies are less common【23–25】.

In primary liver cancers, lymphadenectomy primarily serves a diagnostic-prognostic role. In resectable HCC, lymph node metastasis is relatively rare, with an incidence of 5–10%, particularly lower in HCC associated with cirrhosis【9, 14, 15】. In contrast, the incidence of lymph node metastases in iCCC is significantly higher, at approximately 20–40%.

Although lymphadenectomy is generally advocated for the resection of hepatobiliary tumors, the supporting data remain weak. Given the complexity and variability of hepatic lymphatic drainage, no standardized lymphadenectomy procedure currently exists for liver tumors. Studies have demonstrated that lymph node metastasis negatively impacts the prognosis for tumors of the liver (including liver metastases), pancreas, and bile ducts【14, 34】. The total number of involved lymph nodes and the lymph node ratio (the ratio of positive nodes to total nodes examined) appear to have prognostic relevance, particularly for intrahepatic cholangiocarcinoma (iCCC) and perihilar bile duct carcinoma (PHCC, Klatskin tumors).

Nonetheless, there is consensus that lymphadenectomy should always include the hepatic hilum. However, there remains uncertainty regarding the appropriate extent and “aggressiveness” of lymphatic and connective tissue dissection in the hepatic hilum.

In patients with liver cirrhosis, hilar lymphadenectomy is associated with increased morbidity. Complications include venous bleeding due to portal congestion, frequent respiratory or cardiovascular complications, wound and intra-abdominal infections【14】. Postoperatively, severe lymphatic leakage or massive ascites formation may also occur. Given the multiple postoperative risks, a careful balance between the benefits and risks of lymphadenectomy is essential in cirrhotic patients.

Technical Development of Minimally Invasive Surgical Procedures

Conventional Laparoscopy

The advantages of the minimally invasive approach have been well established over the past two decades in nearly all surgical fields, including colorectal surgery, gynecology, urology, cardiothoracic surgery, bariatric surgery, and surgical oncology.

In 1992, Gagner et al. were the first to describe laparoscopic liver resection in 16 patients with isolated benign and malignant liver tumors, such as symptomatic hemangiomas, focal nodular hyperplasia, hepatic adenomas, colorectal liver metastases, and hepatocellular carcinoma (HCC)【35】. Since then, numerous publications have demonstrated the feasibility and safety of laparoscopic liver resection【36】.

Initially, peripheral wedge or atypical resections were primarily performed. With continuous advancements in surgical techniques and instrumentation, laparoscopic procedures now include larger resections, such as right and left hemihepatectomies and extended hemihepatectomies【36】. In 2009, Yoon et al. demonstrated the feasibility of laparoscopic central liver resections【37】.

Over the years, laparoscopic liver surgery has become increasingly safer due to advancements in operative techniques and improved instruments. Hemorrhage can now be controlled more efficiently and quickly【38】, with only approximately 20% of patients undergoing extensive laparoscopic liver resections requiring intra- or postoperative blood transfusions【39】. Techniques traditionally used in open liver surgery, such as intraoperative ultrasound for precise localization and resection planning of deeply situated or non-visible lesions【40】, are now applied laparoscopically. Resective tools such as the water jet or ultrasonic dissectors (Ultracision) further enhance the effectiveness of laparoscopic resections【41】.

Segment-Specific Resections

• Segments 2 and 3: Laparoscopic resections of segments 2 and 3 are considered routine procedures due to their favorable anatomical location and good visibility【39】
• Segment 4: Segment 4b (ventral portion) is relatively easy to resect laparoscopically, while the deeper, dorsal segment 4a is technically challenging【42】
• Segments 5 and 6: Due to their anterior location, these segments are generally accessible for laparoscopic resection without significant difficulty【43–45】
• Segments 7 and 8: Resections in segments 7 and 8 are far more complex due to their anatomical location, requiring advanced skills. Laparoscopic resection of these segments is comparable in difficulty to a right hemihepatectomy. For deeply situated tumors in segment 7, resection of the posterior section of the right liver lobe is often preferred. For tumors in segment 8, a right hemihepatectomy is commonly recommended【46, 47】
• Segment 1 (Caudate Lobe): Due to its deep location and proximity to the inferior vena cava, laparoscopic resection of the caudate lobe is considered particularly challenging【48】
• The current conversion rate for laparoscopic liver resections is reported to be 3.4 %, with the most common reasons for conversion being uncontrollable bleeding or technical challenges【42】

Advantages of Laparoscopic Liver Resection

• Reduced access trauma【49】
• Significant reduction in intraoperative blood loss while maintaining similar operating time and transfusion requirements【50, 51】
• Lower morbidity rates (5–15%)【39, 42, 50, 52】
• Significantly reduced postoperative pain intensity and duration【53–55】
• Improved early mobilization, leading to enhanced pulmonary and gastrointestinal function【56–58】
• Reduced formation of postoperative abdominal adhesions【53, 55】
• Significant reduction in immunosuppression【59–61】
• Shorter hospitalization【45, 54, 62】
• Faster recovery and earlier return to work【42】
• Lower risk of postoperative hernias【52, 63】

Limitations of Conventional Laparoscopy

Despite its many advantages, conventional laparoscopic liver surgery has inherent limitations, including:

• Restricted range of motion
• Amplification of physiological tremors
• Ergonomic challenges
• Higher time investment【64】
• Higher costs【64】
• Steep learning curve, especially during the early phase, leading to significantly prolonged operating times【42】
• High technical demands on both the surgeon and equipment【65】

Advanced laparoscopic skills, including suturing, knot tying, and bimanual tissue manipulation, are essential for safely performing complex liver, pancreas, and bile duct procedures. Surgeons must have sufficient experience in both open and advanced laparoscopic surgery to perform safe laparoscopic liver resections.

Advancements in Instrumentation and Techniques

The development of specialized instruments for safe and efficient liver surgery has significantly advanced the field of laparoscopic liver surgery【66】. Studies report low postoperative complication rates for both laparoscopic and open liver resections【67–70】.

In appropriately selected patients (e.g., benign liver lesions and small peripheral tumors), laparoscopic liver resection should be the primary approach, as it is associated with shorter hospital stays and lower rates of minor complications while maintaining similar rates of major complications【68, 69】.

Smaller to medium-sized studies have demonstrated the safety of laparoscopic hemihepatectomies【69, 71】. However, for extensive oncologic liver resections, open surgery was previously the standard of care before the advent of robotic surgery【67】.

The primary challenge of conventional laparoscopic liver resection remains the operator’s limited three-dimensional orientation, particularly in complex central lesions and dissection near major vessels. Bleeding complications are the most common reason for conversion to open surgery【69, 71, 72】.

Robotic Surgery in Liver Surgery

Robotic-assisted surgery offers a promising solution to the technical limitations of conventional laparoscopic techniques and is associated with several technical advantages, particularly in liver surgery.

Advantages of Robotic Surgery

Compared to conventional laparoscopy, robotic surgery provides the following key benefits:

• Improved visualization: 3D visualization, greater magnification, and a static image directly controlled by the surgeon
• Seven degrees of freedom: Instrument articulation exceeding that of the human hand
• Enhanced suturing capabilities
• Ambidexterity
• Third operating arm for improved tissue manipulation
• Tremor filtration
• Improved ergonomics for the surgeon

Disadvantages of Robotic Surgery

The disadvantages include:

• Higher operative costs
• Lack of tactile feedback
• Limited workspace in the operative field
• Dependence on an experienced bedside assistant

The lack of tactile feedback can generally be compensated through visual feedback, which improves with increasing experience and practice【73】

Application and Feasibility

The benefits of robotic surgery have led to its adoption for liver resections and bile duct reconstructions in many large hepatobiliary centers for both malignant and benign diseases. Publications evaluating this approach in modern surgical literature are increasing rapidly.

The robotic system enables precise identification and dissection of inflow/outflow vessels and bile ducts, both extra- and intrahepatically. The extrahepatic approach to hilar dissection is facilitated by the 3D visualization, improved dissection angles, magnification, and tremor filtration, making it easier and safer compared to conventional laparoscopy.

Casciola et al. reported that robotic-assisted surgery is particularly advantageous for lesions located high in the liver dome (segments 7 and 8)【74】. The straight nature of conventional laparoscopic instruments often makes accessing the convex surface of the liver dome difficult. The EndoWrist functions of the da Vinci robotic system provide superior access to these challenging areas. Moreover, the robotic system appears to shorten the learning curve for complex procedures compared to conventional laparoscopy.

Skill Development and Procedural Progression

The right hemihepatectomy is not considered an entry-level procedure in robotic liver surgery【75】. According to the classification of difficulty for minimally invasive liver surgery【76】, surgeons should gain experience with minor resections and ideally left hemihepatectomies before attempting this operation.

Choi et al. demonstrated that surgeons without experience in laparoscopic major liver resections could successfully perform large hepatectomies using robotic systems【77】. Therefore, the robotic system can enable surgeons with limited advanced laparoscopic experience to undertake complex minimally invasive procedures safely.

Outcomes and Technical Advancements

The technical benefits of robotics allow for a higher percentage of major resections to be completed purely via a minimally invasive approach. Tsung et al. reported that 93% of robotic liver resections were performed without hand-assisted ports or hybrid techniques, compared to only 49.1% for conventional laparoscopy【78】.

According to numerous authors, the technical demands of most hepatobiliary procedures make them ideal candidates for robotic surgery【79–81】.

In 2003, Guilianotti et al. reported the first series of robotic procedures in general surgery【79】. Their early experience of 207 procedures, including liver and pancreatic resections, concluded that robotic surgery was both safe and feasible. Subsequent reports of robotic liver resections, such as those from Ryska et al. in 2006【83】, and in Germany by Prof. Croner’s group【84–86】, further validated this approach.

Comparison of Robotics vs. Open Surgery

Wong et al. (2019) published a meta-analysis of seven retrospective studies comparing 329 robotic-assisted liver resections to 426 open procedures【88】. Key findings include:

• Longer operative time in the robotic group compared to open surgery (mean difference: 61.67 minutes; 95 % CI: 7.03–115.91)
• No significant difference in blood loss (mean difference: 220.44 ml; 95% CI: -447.47–6.58), blood transfusion risk (RR: 0.78; 95 % CI: 0.33–1.83), or use of the Pringle maneuver (RR: 0.78; 95 % CI: 0.09–11.34)
• Lower conversion rate in the robotic group (4.4 %)
• Lower postoperative complication rates for all complications (RR: 0.63; 95% CI: 0.46–0.86) and severe complications (Clavien-Dindo ≥III) (RR: 0.45; 95 % CI: 0.22–0.94) in robotic resections compared to open surgery
• Shorter postoperative hospital stay in the robotic group (mean difference: -2.57 days; 95 % CI: -3.31 to -1.82)

Comparison of Robotic Surgery vs. Conventional Laparoscopy

Studies comparing robotic surgery with conventional laparoscopic techniques reveal notable differences in outcomes when contrasted with robotic vs. open surgery. Retrospective comparative analyses and meta-analyses suggest several advantages of robotics over conventional laparoscopy, including:

• Lower R1 resection rates
• Reduced mortality
• Lower conversion rates to open surgery
• A flatter learning curve for surgeons【84, 87–89】

However, it is important to note that no prospective randomized studies have been conducted to date, limiting the robustness of current evidence. The cost of robotic surgery remains a persistent criticism. Although intraoperative costs are higher due to material expenses, overall costs can be lower because of shorter hospital stays associated with robotic liver resections【86, 92】. 

Oncological Outcomes in Robotic Liver Surgery

The oncological quality of conventional laparoscopic liver surgery is considered equivalent to that of open liver surgery. Preliminary evidence suggests that robotic liver surgery also achieves comparable oncological results.

• R0 Resection Rates: For malignant liver tumors, the R0 resection rates in robotic-assisted liver resections range from 93 % to 100 %, which is comparable to the 96% reported for open liver resections【86, 87】
• Hepatocellular Carcinoma (HCC):
  • Lai et al. reported a 2-year overall survival and disease-free survival of 94% and 74%, respectively【93】
  • Wang et al. found no significant differences in 1-, 2-, and 3-year disease-free survival between robotic (72.5 %; 64.3 %; 77.8 %) and open surgery (77.8 %; 71.9 %; 71.9 %; p = 0.325)【92】
  • Overall survival after 1, 2, and 3 years was also similar between robotic (95.4 %; 92.3%; 92.3%) and open surgery (100 %; 97.7 %; 97.7 %; p = 0.137). The mean survival time for robotic surgery was 761 days, compared to 686 days for open surgery (p = 0.115)
  • Recurrence rates did not significantly differ: 27% for robotic surgery versus 37.3 % for open surgery (p = 0.140)
• Intrahepatic Cholangiocarcinoma (iCCC) and Gallbladder Carcinoma:
  • Data are limited to smaller case series
  • Khan et al. reported a recurrence rate of 31.2% for iCCC and 27.3% for gallbladder carcinoma after a follow-up period of 75 months following robotic liver resection【95】
  • The 3-year survival rate was 49% for iCCC and 65% for gallbladder carcinoma
• Colorectal Liver Metastases:
  • Troisi et al. reported 1- and 3-year disease-free survival rates of 79% and 62%, respectively, following robotic liver resection【96】 

Summary of Oncological Outcomes

Current publications suggest that robotic liver surgery achieves oncological outcomes comparable to those of open liver surgery. The R0 resection rates, recurrence rates, and long-term survival outcomes are similar for both techniques.

However, it is essential to acknowledge the limited data currently available, particularly for specific tumor types such as iCCC and gallbladder carcinoma, which precludes a definitive assessment.

Conclusion

Robotic liver surgery is a promising innovation that extends the boundaries of minimally invasive techniques, particularly in specialized centers. Its advantages over conventional laparoscopy, including improved visualization, dexterity, and reduced conversion rates, make it a valuable tool for complex liver resections. While evidence regarding oncological outcomes remains preliminary, available data indicate that robotic liver surgery is both safe and effective, with results comparable to open surgery.

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• Impact of a European Training Program for Robotic Liver Surgery (LIVEROBOT) (LIVEROBOT)
• Minimally Invasive Versus Open Liver Resection for Patients With Colorectal Cancer LiverMetastases
• Minimally Invasive Simultaneous Colorectal and Liver Surgery
• Robot-assisted Procedure Versus Open Simultaneous Resection of Colorectal Cancer With LiverMetastases
• Lebensqualität nach robotisch-assistierter Leberresektion
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