Stepwise implementation of robotics and a certified enhanced recovery program significantly improves multiple outcome metrics in a liver surgery unit

INTRODUCTION: Minimally-invasive surgery (MIS - including laparoscopy and robotics) and enhanced recovery after surgery (ERAS®) programs reduce complications and improve functional outcome for cancer patients. Their combined impact on liver surgery cohorts remains unclear. MATERIALS AND METHODS: This Austrian single centre cohort study assesses the stepwise implementation of laparoscopy, robotic-assisted-surgery (RAS), and an audited ERAS® certification. Three periods (17 months each; January 2020 to 06/2024) were compared: P1 (pre-RAS/pre-ERAS®), P2 (RAS/ERAS®-like), and P3 (RAS/ERAS®). Outcomes included intensive-care and overall length-of-stay ((ICU-)LOS), 90-day-morbidity, mortality, post-hepatectomy liver failure, haemorrhage (PHLF/PHH), and bile leakage (BL). Textbook outcome after liver surgery (TOLS) was evaluated in cancer patients (definition: no blood loss >1000 ml, MIS-conversion, PHLF/BL, severe morbidity/mortality, readmission, and R1-margin). RESULTS: Over the three periods n = 225 patients showed comparable demographics, underlying liver disease, preoperative chemotherapy, and major resection rates. MIS (RAS) increased from 31.1 % (0 %), to 71.1 % (52.6 %), and 77.3 % (45.6 %; p < 0.001), with less conversions (21.1 %, to 3.7 %, and 5.9 %; p = 0.030). Decreasing median blood-loss (400 ml-200 ml in P3; p = 0.002) led to low transfusion rates (P3: 5.7 %). Median LOS/ICU-LOS decreased from 9/3 days, to 6/2, and 5/1 days (p < 0.001), overall (severe) 90-day-morbidity from 54.1 % (29.5 %), to 39.5 % (14.5 %), and 35.2 % (14.8 %) (p = 0.022/p = 0.011). PHLF reduced from 13.1 %, to 1.3 %, and 5.7 % (p = 0.009). TOLS rates enhanced from 37.9 %, to 68.2 %, and 70.8 % (p = 0.002). MIS was an independent predictor of lower (severe) morbidity and LOS. CONCLUSIONS: Implementing MIS/RAS and ERAS® in an established hepatobiliary unit significantly improves blood-loss, (ICU-)LOS, morbidity, and PHLF. This ultimately leads to substantially increased TOLS rates in common oncological indications.