title: The safety and efficacy of approaches to liver resection: a meta-analysis.
abstract: BACKGROUND
  The aim of this study is to compare the safety and efficacy of conventional laparotomy with those of robotic and laparoscopic approaches to hepatectomy.
  
  
  METHODS
  Independent reviewers conducted a systematic review of publications in PubMed and Embase, with searches limited to comparative articles of laparoscopic hepatectomy with either conventional or robotic liver approaches. Outcomes included total operative time, estimated blood loss, length of hospitalization, resection margins, postoperative complications, perioperative mortality rates, and cost measures. Outcome comparisons were calculated using random-effects models to pool estimates of mean net differences or of the relative risk between group outcomes. Forty-nine articles, representing 3702 patients, comprise this analysis: 1901 (51.35%) underwent a laparoscopic approach, 1741 (47.03%) underwent an open approach, and 60 (1.62%) underwent a robotic approach. There was no difference in total operative times, surgical margins, or perioperative mortality rates among groups. Across all outcome measures, laparoscopic and robotic approaches showed no difference. As compared with the minimally invasive groups, patients undergoing laparotomy had a greater estimated blood loss (pooled mean net change, 152.0 mL; 95% confidence interval, 103.3-200.8 mL), a longer length of hospital stay (pooled mean difference, 2.22 days; 95% confidence interval, 1.78-2.66 days), and a higher total complication rate (odds ratio, 0.5; 95% confidence interval, 0.42-0.57).
  
  
  CONCLUSIONS
  Minimally invasive approaches to liver resection are as safe as conventional laparotomy, affording less estimated blood loss, shorter lengths of hospitalization, lower perioperative complication rates, and equitable oncologic integrity and postoperative mortality rates. There was no proven advantage of robotic approaches compared with laparoscopic approaches.
authors.affiliation: Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
authors.forename: Nicole R
authors.initials: NR
authors.lastname: Jackson
authors.affiliation: Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
authors.forename: Adam
authors.initials: A
authors.lastname: Hauch
authors.affiliation: Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
authors.forename: Tian
authors.initials: T
authors.lastname: Hu
authors.affiliation: Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Buell
authors.affiliation: Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
authors.forename: Douglas P
authors.initials: DP
authors.lastname: Slakey
authors.affiliation: Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
authors.forename: Emad
authors.initials: E
authors.lastname: Kandil
mesh_terms: D005260:Female; D006498:Hepatectomy; D006801:Humans; D010535:Laparoscopy; D007813:Laparotomy; D008297:Male; D061646:Operative Time; D065287:Robotic Surgical Procedures
keywords: Hepatectomy; Laparoscopy; Meta-analysis; Minimally invasive surgery; Robotics
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