Robotic versus laparoscopic versus open hepatectomy for hepatocellular carcinoma: a systematic review and network meta-analysis

Robotic hepatectomy has recently been developed as an alternative to laparoscopic and open approaches for hepatocellular carcinoma (HCC) treatment. However, comparative studies are lacking. We conducted a PRISMA-NMA–compliant systematic review (PROSPERO CRD420251265604) of databases, comparing robot-assisted hepatectomy with laparoscopic/open resection for adult HCC. We used ROBINS-I to assess bias and GRADE to assess evidence. Frequentist random-effects NMA estimated OR/MD, with consistency, ranking, and CINeMA certainty. A total of 23 studies (9,666 patients) were included. Overall complications (OR 0.52, 95% CI 0.35–0.77) and major complications (OR 0.44, 95% CI 0.28–0.67) were significantly less frequent after robotic hepatectomy than open surgery. Robotic surgery was associated with less blood loss (MD − 144.6 mL) and shorter hospital stay (MD − 3.0 days). The conversion rate was lower during robotic than laparoscopic surgery (OR 0.43, 95% CI 0.24–0.75). Robotic hepatectomy ranked first in 8 of 11 outcomes. Subgroup analysis stratified by extent of hepatectomy showed that the robotic advantage was most pronounced for major resections, with a 66% reduction in major complications compared with open surgery (OR 0.34, 95% CI 0.14–0.84, p = 0.019). This network meta-analysis, based entirely on retrospective observational data, suggests that robotic hepatectomy is associated with favorable perioperative outcomes compared with open surgery for HCC, including lower complication rates, reduced blood loss, and shorter hospital stay, while maintaining comparable oncological results. Robotic surgery was also associated with a lower conversion rate than laparoscopy. Exploratory subgroup analysis suggested a possible trend toward amplified benefits in major hepatic resections; however, this is based on limited data. These results must be interpreted with caution, given the entirely observational evidence base and potential for residual confounding. Robotic hepatectomy may be considered a viable surgical option for HCC when institutional resources and expertise permit.