Advances and Current Evidence in Minimally Invasive Hepatobiliary Surgery: A Review of Laparoscopic and Robotic Approaches

The field of hepatobiliary surgery is undergoing a significant paradigm shift, transitioning from conventional open approaches toward increasingly sophisticated minimally invasive techniques, including laparoscopic and robotic surgery. This review critically examines the contemporary evidence supporting minimally invasive liver surgery (MILS), tracing its progression from minor resections to complex oncologic procedures and applications in liver transplantation. Current data consistently demonstrate that laparoscopic and robotic liver resections are associated with improved short-term perioperative outcomes compared with open surgery. These benefits include reduced intraoperative blood loss, lower transfusion requirements, and shorter lengths of hospital stay. Importantly, in both primary and secondary hepatic malignancies—such as hepatocellular carcinoma and colorectal liver metastases—MILS achieves oncological outcomes equivalent to open surgery, with comparable rates of margin negativity, recurrence, and long-term survival. The advent of robotic-assisted surgery represents a further evolution in MILS, addressing several technical constraints of conventional laparoscopy. Enhanced three-dimensional visualization, tremor suppression, and articulated instrumentation facilitate precise dissection and suturing, particularly in technically demanding hepatectomies, including resections of posterosuperior segments and complex staged procedures such as associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). These advantages may translate into reduced operative difficulty and physiological stress in selected patients. Despite its growing adoption and recognition as a standard approach in high-volume centers, the widespread implementation of MILS remains limited by cost considerations, unequal access to advanced technology, and a steep learning curve. This review concludes that while minimally invasive liver surgery is firmly established, further high-quality randomized controlled trials and standardized training pathways are essential to optimize outcomes, ensure oncological rigor, and promote safe global dissemination of these techniques.