Open Versus Laparoscopic and Robotic Approach in Hilar Cholangiocarcinoma: A Network Meta‐Analysis With Trial Sequential Analysis

BACKGROUND: The use of minimally invasive (MI) techniques for Hilar cholangiocarcinoma (HCCA) has increased in the last years, but high-quality evidence remains limited. This study aims to assess the safety of laparoscopic (LPS) and robotic (ROB) approaches compared to open surgery in the treatment of HCCA. METHODS: After a systematic search, a frequentist network meta-analysis and a Trial sequential analysis were performed. Primary outcomes set for the study were major complications and R0 rate. RESULTS: Fourteen studies including 1169 patients were found eligible, of which 403 were LPS (34.5%) and 137 operated with a ROB approach (11.7%). ROB and LPS techniques showed statistically similar rates of major complications (p = 0.251 and p = 0.143), while ROB was associated with a higher rate of negative resection margins (OR: 2.856, 95% CI: 1.585-5.144; p < 0.001). No differences were observed in the secondary outcomes assessed, except for the operative time, higher in both MI approaches, and length of stay, shorter in the ROB group. CONCLUSIONS: Global experience in MI surgery for HCCA remains limited and subject to potential bias. Nevertheless, both LPS and ROB approaches seem to represent safe and viable options for carefully selected patients when performed by experienced surgeons in high-volume centers.