Safe Unplanned Open Conversion During Robotic Hepatectomy for Major Bleeding

The worldwide diffusion of minimally invasive liver surgery (MILS) over the last three decades [1] has led to the expansion of the number of centers performing laparoscopic and robotic resections as well as the increase of the possible indications and is no longer limited to small peripheral lesions located in the anterior segments [2–4]. Robotic-assisted surgery overcame several limitations of the laparoscopic technique [5, 6], allowing more surgeons to manage more complex liver resections with a minimally invasive approach. MILS has been demonstrated to be able to offer significant advantages both in minor and major hepatectomies [1], but despite the technical progress and the increased skills, in 4–26% of cases, the surgical team opts to convert from minimally invasive to open surgery [7]. This decision can be the result of a lack of progression and therefore be performed electively or determined by an intraoperative complication and therefore being performed as an emergency procedure. In both scenarios, the timing of the conversion is of paramount importance to minimize the entity of the negative impact that can affect patients’ outcomes [8]. Intraoperative bleeding represents the most frequently reported cause of open conversion during laparoscopic hepatectomies, accounting for approximately one-third of cases, followed by oncological concerns and adhesions [8–11]. Intraoperative bleedings during liver resections most frequently originate from major vessels during dissection or mobilization maneuvers, from the liver parenchyma during the transection, or from other non-hepatic structure injuries. At higher risk of experiencing intraoperative bleeding are patients affected by cirrhosis, due to impaired coagulation, the diseased liver parenchyma, the distorted anatomy, and the presence of portocaval shunts in case of portal hypertension. Similarly to laparoscopic liver resections, robotic-assisted hepatectomies have bleeding and oncological reasons as the most frequent indications for open conversions [12]. Compared to laparoscopy, the robotic approach has shown to reduce by 60% the risk of open conversion during major hepatectomies, with rates as low as 5% [11, 13], but analyses performed on minor, low-difficulty resections failed to demonstrate these superior results [14, 15]. It needs to be pointed out that the available data on robotic liver resection are far more limited than the ones on laparoscopic resections, and that may be affected by a selection bias [7].