Minimally invasive liver surgery Enhancing outcomes through innovation

This thesis evaluates the implementation and outcomes of laparoscopic and robotic liver surgery and the role of ablative techniques in optimizing minimally invasive liver treatment. Laparoscopic liver surgery offers important perioperative benefits compared with open surgery, including fewer complications and shorter hospital stays, without compromising oncological outcomes. Laparoscopic hemihepatectomy is also associated with improved quality of life and a high probability of being cost-effective despite higher in-hospital costs. Robotic liver surgery has rapidly gained adoption and appears to offer additional technical advantages over laparoscopy, particularly lower conversion rates, reduced blood loss, and shorter hospital stays. However, these benefits are largely driven by avoidance of conversion, as outcomes following completed laparoscopic and robotic procedures are otherwise broadly comparable, while the higher costs of robotic surgery remain an important consideration. Conversion to open surgery is a key determinant of outcomes following minimally invasive liver resection. Whereas elective conversion can achieve outcomes comparable to planned open surgery, emergency conversion is associated with substantially higher morbidity and mortality. Identifying patients at increased risk of conversion and preventing emergency conversion are therefore important considerations in patient selection and surgical planning. Finally, this thesis highlights substantial variation in the implementation of combined ablation and resection (CARe) across Europe and demonstrates the feasibility of a novel strategy combining robotic liver resection with cone beam CT-guided ablation. Overall, these findings support the continued development and structured implementation of minimally invasive liver surgery in experienced centres, with emphasis on appropriate patient selection, training, and continuous outcome evaluation.