Importance Total pancreatectomy (TP) is indicated for advanced pancreatic cancer or multifocal tumors. Furthermore, TP may be performed to avoid the risk of pancreatic fistula in selected patients to improve the perioperative risk profile. Objective To define reference values for TP based on a low-risk cohort treated at expert centers. Design, Setting, and Participants This multicenter study analyzed outcomes from patients undergoing primary TP for malignant or benign lesions from 25 international expert centers from January 2017 to November 2023. Low-risk patients undergoing TP (LR-TP) were without vascular resections or significant comorbidities. Exposures TP. Main Outcomes and Measures Twenty reference values were derived from the 75th or the 25th percentile of the median values of all centers. Outcomes of LR-TP were compared with a cohort of TP with vascular resection, TP due to high-risk pancreatic anastomosis, and the benchmark values for low-risk pancreatoduodenectomy. Results Of 994 patients, 333 (33.5%; median [IQR] age, 66 [58-72] years; 171 male [51.4%]) qualified as the LR-TP cohort. Reference values included blood loss (≤1000 mL), major complications (≤37%), 3-month postoperative mortality (<6%), and retrieved lymph nodes (≥29). Compared with TP with vascular resections, reference cutoffs were not met for major complications (51% vs LR-TP ≤37%) and 90-day mortality (11% vs LR-TP ≤6%). For TP due to high-risk anastomosis, failure to rescue rate (38% vs ≤6%) and 90-day mortality (11% vs LR-TP ≤6%) were not met. Compared with pancreatoduodenectomy, reference values for postoperative mortality were 3 times higher for LR-TP (≤2% vs ≤6%) and less for resected lymph nodes (≥16 vs ≥29). Conclusions and Relevance This case-control study provided global reference values for TP, indicating significantly higher postoperative morbidity and mortality compared with pancreatoduodenectomy. Perioperative morbidity of TP was especially increased in patients with vascular resections. These reference values can serve for quality control of pancreatic surgery.

Objective: To evaluate the institutional learning curve of robotic liver resection (RLR), its association with surgical complexity and outcomes in an international multicenter cohort. Summary of Background Data: RLR is increasingly adopted worldwide, but the dynamics of the learning process and its impact on surgical outcomes remain poorly defined. Methods: This international, multicenter, retrospective cohort study included consecutive patients who underwent RLR between 06/2013 and 12/2024 across 22 expert centers. Based on the first 150 cases at each center, three phases were used to define the learning curve: operative time for competency, major complications for proficiency, and textbook outcome for mastery. Risk-adjusted generalized additive models were used to assess the learning process. Benchmark performance was compared to international reference values. Results: Among 2,331 patients, the most common indications were hepatocellular carcinoma (36%), benign lesions (23%) and colorectal liver metastases (21%). Operative time decreased after achieving competency (case #62), from 240 to 220 minutes ( P <0.001). Major morbidity reached a plateau during the proficiency phase (cases #63–138; 9% vs. 11%, P =0.144), while progression to mastery (cases #139–150) was associated with a higher rate of textbook outcome (76% vs. 87%, P =0.021). In contrast, conversion (5.1% vs. 4.9% vs. 2%), bile leak (4.0% vs. 5.3% vs. 3.8%), and 90-day mortality (0.7% vs. 0.9% vs. 0.9%) remained low and stable across all learning phases. Importantly, benchmark criteria for operative time, hospital stay, and textbook outcome were met across all complexity groups, including during the early learning phase. Conclusions: Robotic liver surgery shows progressive outcome improvement with early achievement of benchmark-level results and stable performance across increasing complexity. These findings indicate that, in experienced centers, RLR can be safely implemented and integrated into clinical practice, supporting its key role in modern hepatobiliary surgery.

Objective:. To compare perioperative outcomes of minimally invasive pancreatoduodenectomy (MIPD) to open pancreatoduodenectomy (OPD) using evidence from randomized controlled trials (RCTs). Background:. The wider adoption of MIPD has largely been fueled by observational studies rather than high-level evidence. Methods:. We searched Cochrane Central Register of Controlled Trials, MEDLINE, and Web of Science for RCTs comparing MIPD with OPD in adult patients with benign or malignant conditions requiring elective pancreatoduodenectomy. The primary outcomes were 90-day mortality, the comprehensive complication index, Clavien-Dindo grade ≥III complications, and hospital length of stay (LOS). Secondary outcomes included postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), blood loss, reoperation, operative time, and oncologic outcomes. Data were pooled as odds ratios or mean differences using a random-effects model. Risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of evidence was evaluated according to the Grading of Recommendations Assessment, Development and Evaluation approach (PROSPERO ID: CRD42024592919). Results:. Ten RCTs with a total of 1794 patients were included. Meta-analysis showed there were no significant differences regarding 90-day mortality, Clavien-Dindo ≥3 complications, POPF, DGE, PPH, reoperation, readmission, or oncologic outcomes between MIPD and OPD. LOS was reduced for MIPD. No clinically relevant differences were found in the subgroup analyses of laparoscopic and robotic pancreatoduodenectomy. Certainty of evidence was moderate to low. Conclusions:. MIPD showed no clinically relevant advantages over OPD. These findings were consistent both for the robotic and laparoscopic approach.

OBJECTIVE:To evaluate the institutional learning curve of robotic liver resection (RLR), its association with surgical complexity and outcomes in an international multicenter cohort. SUMMARY OF BACKGROUND DATA:RLR is increasingly adopted worldwide, but the dynamics of the learning process and its impact on surgical outcomes remain poorly defined. METHODS:This international, multicenter, retrospective cohort study included consecutive patients who underwent RLR between 06/2013 and 12/2024 across 22 expert centers. Based on the first 150 cases at each center, three phases were used to define the learning curve: operative time for competency, major complications for proficiency, and textbook outcome for mastery. Risk-adjusted generalized additive models were used to assess the learning process. Benchmark performance was compared to international reference values. RESULTS:Among 2,331 patients, the most common indications were hepatocellular carcinoma (36%), benign lesions (23%) and colorectal liver metastases (21%). Operative time decreased after achieving competency (case #62), from 240 to 220 minutes (P<0.001). Major morbidity reached a plateau during the proficiency phase (cases #63-138; 9% vs. 11%, P=0.144), while progression to mastery (cases #139-150) was associated with a higher rate of textbook outcome (76% vs. 87%, P=0.021). In contrast, conversion (5.1% vs. 4.9% vs. 2%), bile leak (4.0% vs. 5.3% vs. 3.8%), and 90-day mortality (0.7% vs. 0.9% vs. 0.9%) remained low and stable across all learning phases. Importantly, benchmark criteria for operative time, hospital stay, and textbook outcome were met across all complexity groups, including during the early learning phase. CONCLUSIONS:Robotic liver surgery shows progressive outcome improvement with early achievement of benchmark-level results and stable performance across increasing complexity. These findings indicate that, in experienced centers, RLR can be safely implemented and integrated into clinical practice, supporting its key role in modern hepatobiliary surgery.

BACKGROUND:A deep understanding of anatomy is essential for the professional education of competent clinicians, especially surgeons. This study explores an innovative format of live surgery on body donors complemented by interactive digital technologies and assesses its perceived educational value among students. By evaluating the individual digital technologies, this study also evaluates the format's practical feasibility as a testing platform for digital technologies in surgical anatomy education. METHODS:Operations were performed on body donors by experts in a live format in front of an audience of 40-80 medical students. Surgeons and anatomy specialists interacted with students and explained procedures step by step. Students actively participated in the operations, gaining direct practical experience. In addition, the latest digital interactive technologies, such as virtual reality (VR) and augmented reality (AR), were continuously used and evaluated. RESULTS:Evaluations demonstrated that 96% of 412 participants were 'very enthusiastic' about the concept and appreciated the use of multimedia teaching methods. The Touch Surgery app was well received (mean 3.2 ± SD 1.3; Likert scale 1-5, where 5 indicated 'fully applies'). By using interactive platforms such as Slido and TED, the contents could be repeated and prepared, which was highly appreciated (mean 4.4 ± SD 1.1; Likert scale 1-5, where 5 indicated 'fully applies'). In particular, the use of computed tomography (CT) scans of the body donors was rated positively (mean 3.6 ± SD 1.4; Likert scale 1-5, where 5 indicated 'fully applies'). CONCLUSIONS:Live surgery using body donors improved not only the students' self-reported anatomical knowledge but also the innovative digital technologies with a focus on VR and, in particular, the complementary use of CT datasets of body donors, were perceived positively. This new format is a valuable addition to the standard medical curriculum, providing students with further tools for a better understanding of surgical anatomy and potentially supporting greater confidence in long-term clinical practice.

Objective:The aim of this study was to evaluate the different phases of the learning curve for robotic distal pancreatectomy (RDP) in international expert centers.Background:RDP is an emerging minimally invasive approach; however, only limited, mostly single-center data are available on its safe implementation, including the learning curve.Methods:Consecutive patients undergoing elective RDP from 16 expert centers across 3 continents were included to assess the learning curve. Based on the first 100 RDPs at each center, 3 cutoffs were used to define the learning curve: operative time for competency, major complications (Clavien-Dindo grade >= III) for proficiency, and textbook outcome for mastery. Clinical outcomes before and after the cutoffs were compared.Results:The learning curve analysis was conducted on 1109 of 2403 RDPs. Competency, proficiency, and mastery, respectively, were reached after 46, 63, and 73 RDP procedures. After competency, operative time decreased from 245 to 235 minutes (P = 0.002). Attaining proficiency was reflected by a reduction in the rate of major complications from 20% to 15% (P = 0.012), and mastery was associated with a higher proportion of patients with textbook outcomes (71% vs 63%; P = 0.028). The postoperative pancreatic fistula rate remained stable along the learning curve, ranging between 18.5% and 21.5%. Previous laparoscopic experience accelerated the learning process by virtue of reduced operative time and an earlier decrease in major complications.Conclusions:Competency, proficiency, and mastery for RDP were reached after 46, 63, and 73 procedures, respectively, at international expert centers. The findings highlight that the learning curves for intraoperative parameters are completed earlier; however, extensive experience is needed to master RDP.

Background Whether prolonged antibiotic prophylaxis (PAP) enhances the outcomes of pancreatoduodenectomy (PD) in patients with preoperative biliary drainage (PBD) remains controversial. The aim of this retrospective, bicentric study was to determine whether PAP reduced the incidence of infection following PD. Methods Group 1 received a single dose of antibiotic prophylaxis (SDAP), while group 2 received SDAP and PAP for five days. Postoperative complication rates were compared using bipartite propensity score matching (PSM) and weighting, Cox regression and mediation analysis. Results Of the 234 eligible patients with PBD who underwent PD (SDAP, n = 147; PAP, n = 87), 173 were matched in the PSM analysis (SDAP, n = 114; PAP, n = 59). There was no significant difference between PAP and SDAP in terms of superficial SSI (30.5 v. 22.8%; P = 0.270), deep incision SSI (3.4 vs. 5.3%; P = 0.623) or deep organ SSI (6.8 vs. 8.8%; P = 0.678). Both groups had similar rates of grade B POPF (13.6 vs. 10.5%; P = 0.554), grade C POPF (11.9 vs. 5.3%; P = 0.140), PPH (15.3 vs. 13.2%; P = 0.705) and bile leakage (5.1 vs. 1.8%; P = 0.265). PAP was linked to a higher 90-day postoperative mortality rate (13.6% vs. 4.4%; P = 0.042). According to the mediation analysis, the overall pure natural direct effect of PAP on the 90-day mortality rate had a risk ratio of 3.29 (95% CI: 1.28-25.2). Discussion Our analysis based on PSM and mediation suggested that SDAP may effectively prevent postoperative infectious complications in patients with PBD who are undergoing PD. Therefore, we do not recommend PAP routinely for such patients.

Background & Aims: Liver transplantation (LT) for hepatocellular carcinoma (HCC) is performed worldwide, with 5-year survival rates of approximately 70%. However, post-transplant HCC recurrence occurs in 15-20% of recipients. We aimed to evaluate, for the first time, long-term recurrence-free survival in a large international cohort of patients undergoing LT for HCC using grafts treated with hypothermic oxygenated machine perfusion (HOPE). Methods: This observational post hoc analysis of the multicenter European HOPE-REAL study (NCT05520320) included adult recipients with HCC (N = 599) who received a liver from either a donation after brain death (DBD) or donation after circulatory death (DCD) donor, preserved using HOPE, dual-HOPE (DHOPE), or normothermic regional perfusion followed by HOPE (NRP-HOPE) between 2012 and 2022. Propensity score matching was used to compare outcomes between HCC and non-HCC recipients within the HOPE-REAL cohort, and between HOPE-treated HCC recipients and an external control cohort receiving non-perfused livers (n = 484). Results: The overall HCC recurrence rate in the HOPE-REAL cohort was 6.9% (41/599), with no significant difference between DBD and DCD liver transplants (7.1% [25/350] vs. 6.4% [16/249]; p = 0.346). One-, 3-, and 5-year overall survival rates were 92%, 86%, and 81%, while recurrence-free survival rates were 90%, 83%, and 78%, respectively. Five-year overall survival was similar between 347 HOPE-treated HCC recipients (82%) and 347 matched non-HCC recipients (84%) (p = 0.625). In contrast, compared to an external cohort of 312 non-perfused HCC recipients, 5-year overall survival was significantly higher in 312 matched HOPE-treated HCC recipients (74% vs. 84%; p = 0.034). Conclusions: HCC recurrence was rare after transplantation of livers treated with HOPE. Long-term survival in HOPE-treated HCC recipients was significantly better than in those receiving non-perfused livers, and comparable to outcomes in non-HCC recipients. These findings warrant validation in a randomized clinical trial. Impact and implications: This post hoc analysis of the HOPE REAL study demonstrates, for the first time, low hepatocellular carcinoma (HCC) recurrence rates in a large cohort of hypothermic oxygenated machine perfusion-treated liver transplant recipients with HCC, and significantly better survival outcomes compared to matched recipients of non-perfused grafts. These findings may have important implications, particularly as tumor-related indications for liver transplantation continue to rise. Machine liver perfusion could emerge as a novel strategy to improve oncological outcomes in high-risk cancer conditions after transplantation, potentially via mitigation of inflammation and reduced tumor cell seeding. Clinical trial number: NCT05520320

Indocyanine green (ICG) fluorescence imaging is increasingly incorporated into robotic liver resections (RLR), yet clinical practice regarding timing, dosage, and staining techniques is divergent. This international expert survey aimed to characterize current practices for ICG in RLR. Experts in RLR were invited to participate based on surgical volume (experience of ≥ 50 RLR and ≥ 30 annual RLR). A 74-item questionnaire was developed following a literature search and reviewed by a steering committee. The survey addressed indications, timing, dosage, imaging technology, benefits, limitations, training, and future directions of ICG use. Responses collected between September and October 2025 were analyzed. Seventy experts from 19 countries completed the survey, corresponding to an 88

Artificial intelligence (AI), machine learning (ML), and image guidance are increasingly being used to support surgeons in preoperative, intraoperative, and postoperative decision making and optimized patient care. Surgery is the cornerstone of curative treatment in pancreatic diseases, and a large amount of perioperative data are becoming available with the widespread application of minimally invasive surgical techniques. AI is showing promise in the prediction of malignancy and resectability from preoperative images. A further clinical focus is the prediction of postoperative complications, especially pancreatic fistula, and several AI algorithms now outperform conventional fistula risk scores. Future research will be directed toward refinement of intraoperative decision support systems, individualization of surgical training, and improvement of pre- and postoperative oncologic risk stratification to personalize the sequence of surgery and chemotherapy. This review summarizes recent developments in AI and image guidance for pancreatic surgery.

INTRODUCTION:Surgical process models (SPM) are simplified representations of operations and their visualization by surgical workflow management systems (SWMS), and offer a solution to enhance communication and workflow. METHODS:A 1:1 randomized controlled trial was conducted. A SPM consisting of six surgical steps was defined to represent the surgical procedure. The primary outcome, termed "deviation" measured the difference between actual and planned surgery duration. Secondary outcomes included stress levels of the operating team and complications. Analyses employed Welch t-tests and linear regression models. RESULTS:18 procedures were performed with a SWMS and 18 without. The deviation showed no significant difference between the intervention and control group. Stress levels (TLX score) of the team remained largely unaffected. Duration of operation steps defined by SPM allows a classification of all liver procedures into three phases: The Start Phase (low IQR of operation time), the Main Phase (high IQR of operation time) and the End Phase (low IQR of operation time). CONCLUSION:This study presents a novel SPM for open liver resections visualized by a SWMS. No significant reduction of deviations from planned operation time was observed with system use. Stress levels of the operation team were not influenced by the SWMS.

Robotic pancreatic surgery is complex, and its establishment in an institution require a structured approach to secure optimal short- and long-term outcomes. This article provides a structured training proposition for robotic pancreatic surgery and gives an overview of the learning curves and examines the key takeaways.The preclinical training in robotic pancreatic surgery can be divided into a basic and advanced phase. The basic phase includes virtual reality training, biotissue drills, and specialized training courses. The advanced phase consists of reaching benchmarks for the biotissue drills and completing video-based training. After establishing a dedicated interprofessional surgical team index procedures and first robotic pancreatic cases can be performed under the supervision of a proctor.Three phases of clinical training are proposed: competency, proficiency, and mastery. Competency referring to be able to perform the procedure without supervision in patients without risk factors and with average technical difficulty. Proficiency signifying consistently reaching benchmark- and textbook outcome in patients with risk factors and extended indications. Mastery is achieving benchmark values for morbidity rates even in complex cases requiring vessel or multi-visceral resections and with patients having multiple risk factors.The number of cases to overcome the initial phase of the learning curve vary between 7 and 46 for robotic distal pancreatectomy and 8–100 for robotic partial pancreaticoduodenectomy. Significantly longer learning phases of 60–200 cases are reported to complete all three learning phases.In conclusion the hallmarks for safe and efficient implementation of robotic pancreatic surgery are a dedicated team, structured training program and stepwise patient selection.

BACKGROUND:This study aimed to compare the accuracy of the Comprehensive Complication Index (CCI) with that of the Clavien-Dindo classification in patients undergoing pancreatoduodenectomy. METHODS:A two-centre, retrospective study was undertaken that included patients who underwent pancreatoduodenectomy between 2008 and 2022. Three approaches were used to assess the two complication scores: the Spearman rank test, yielding the correlation coefficient (r), the area under the curve with 95% confidence intervals, and a mixed-effects model and a generalized mixed-effects model that yielded odds ratios and β-coefficients. RESULTS:A total of 596 patients were included. The CCI and Clavien-Dindo classification demonstrated no correlation with 90-day mortality (r = - 0.021, 0.618; and r = -0.003, P = 0.951) but a significant correlation with length of hospital stay (r = 0.620, P < 0.001; and r = 0.605, P < 0.001) and with 90-day readmission rate (r = 0.148, P < 0.001; and r = 0.120, P = 0.005). The accuracy of the CCI was superior to that of the Clavien-Dindo classification for length of hospital stay dichotomized at the 75th (P = 0.022) and 90th (P < 0.001) percentiles. The CCI significantly improved the effect of the Clavien-Dindo classification (random effect, P < 0.001) in the mixed-effects and generalized mixed-effects logistic regression analyses. CONCLUSION:Compared with the Clavien-Dindo classification, the CCI appeared to be more accurate in terms of its association with a prolonged hospital stay and 90-day readmission rate. The CCI should complement the Clavien-Dindo classification in clinical and research settings.

Objective: The aim of this study was to identify risk factors for conversion and assess its consequences on clinical outcomes after robotic distal pancreatectomy (RPD). Summary of Background Data: RDP has gained popularity due to its lower conversion rate (3–8%) when compared to laparoscopic distal pancreatectomy (10–20%). Methods: This retrospective multicenter study included RDPs performed at 16 international centers from May 2007 to March 2024. Perioperative outcomes of patients requiring conversion were compared to fully robotic RDP patients. Risk factors for conversion were identified by multivariable logistic regression analysis. Results: Of 2,452 patients undergoing RDP, 75 (3.1%) required conversion to open surgery. In converted RDPs, operative time was longer (300 (243–376) vs. 180 (120–240) minutes; P <0.001), and blood loss was greater (500 (200–990) vs. 100 (50–200) ml; P <0.001). Converted patients experienced more overall complications (53% vs. 39%; P =0.017), major complications (41% vs. 25%; P <0.001), and a higher 90-day mortality (5% vs. 3%; P <0.001). Furthermore, both postoperative pancreatic fistula (35% vs. 18%; P <0.001) and delayed gastric emptying (10% vs. 3%; P <0.001) were more frequent in the conversion group. The rate of patients achieving textbook outcome was lower after conversion (57% vs. 74%; P =0.003). In the multivariable analysis, lesion size (>51 mm; OR 2.86 (95% CI 1.56–5.08)), BMI (>28 kg/m 2 ; OR 3.03 (1.75–5.30)), previous abdominal surgery (OR 2.48 (1.31–4.51)), patients outside benchmark criteria (OR 2.09 (1.19–3.72)), and age (>62 years; OR 2.21 (1.24–4.05)) were associated with conversion. Conclusion: This international cohort study confirmed a very low conversion rate for RDP. Yet, converted cases experienced substantially impaired postoperative outcomes, highlighting the need for adequate patient selection through validated difficulty scoring systems.

A frequent and increasing indication for liver transplantation (LT) is hepatocellular carcinoma (HCC). However, despite strict selection criteria, HCC recurrence after LT occurs in a relevant proportion of patients and is associated with an unfavorable prognosis. Hypothermic oxygenated perfusion (HOPE) is a novel machine liver perfusion approach to optimize liver grafts before implantation and has been suggested to decrease graft inflammation with potential anti-cancer effects. HOPE4Cancer is an international, multicentric, parallel group, randomized controlled trial comparing HOPE performed after initial cold storage (intervention) with conventional cold storage alone (control) in a 1:1 allocation ratio. Adult recipients with proven HCC will be included for transplantation of a DBD (donation after brain death) Liver graft. The minimum perfusion duration is defined at 2 h and perfusion is generally continued until the recipient hepatectomy is completed. The conventional cold storage at 4 °C will be performed with a precooled preservation solution according to the local standard of care. The primary endpoint is defined as post-transplant HCC recurrence-free survival, i.e., the time interval a patient is alive without HCC recurrence after transplantation. Secondary endpoints are the single components of the events considered for the primary outcome (i.e., HCC recurrence, HCC-related death, death from any other causes than HCC), circulating tumor DNA, high-mobility-group-protein B1 in the blood, the Rejection Activity index, and the number of liver-related complications experienced by the patient. HOPE4Cancer investigates if cold storage plus end-ischemically applied HOPE in DBD LT is superior to conventional cold storage of liver grafts in terms of post-transplant HCC recurrence-free survival. The results will indicate for the first time whether ex situ HOPE before transplant has an anti-cancer potential compared to transplantation of un-perfused livers. ClinicalTrials.gov NCT06717919. Registered on December 5, 2024.

Postoperative pancreatic fistula (POPF) remains the most severe complication following distal pancreatectomy (DP). The preoperative distal fistula risk score (D-FRS) was recently introduced to predict the POPF risk. The aim of this study was to externally validate the D-FRS in an international expert center cohort. This international, multicenter, retrospective cohort study included open and minimally invasive DP for benign and malignant lesions performed from 01/2014 until 12/2023 in 12 centres from 6 countries, that each performed more than 50 pancreatectomies annually. The D-FRS was calculated from pancreatic thickness and duct size. Predicted and actual POPF were compared using sensitivity, specificity and area under the curve (AUC). A total of 778 patients underwent DP of whom 284 (39%) underwent robotic, 278 (38%) open and 165 (23%) laparoscopic DP. The rate of POPF was 32%. In the POPF group, the D-FRS was 0.21 (0.13-0.33), while in the no-POPF group it was 0.23 (0.15-0.36). The sensitivity, specificity and AUC of the D-FRS for the overall cohort was 32%, 63% and 48% (95% CI 44-51), respectively. The AUC for open, laparoscopic and robotic DP was 54% (48-60), 47% (39-55) and 45% (39-50), respectively. On multivariate analysis POPF was associated with BMI (odds ratio 1.04 (95% CI 1.01-1.07)), protective factors were neoadjuvant therapy (OR 0.54 (0.22-0.94)) and robotic approach (OR 0.64 (0.42-0.97)). The preoperative D-FRS showed insufficient discrimination to identify patients who develop POPF after DP irrespective of the surgical approach. Novel preoperative POPF risk scores are needed, taking into account the standard robotic approach and the widespread application of a no-drain policy.

Objective:This study aimed to identify benchmark values for robotic right hepatectomy (RH) based on a low-risk cohort treated at expert centers. Background:Robotic liver surgery is emerging as a preferred minimally invasive approach to the liver. To enable conclusive comparisons with the standard open or laparoscopic approaches, reference values are needed. Methods:Outcomes from consecutive patients undergoing robotic RH for malignant or benign indications at 22 international expert centers between 2018 and 2024 were analyzed. Low-risk, benchmark patients were without significant comorbidities such as portal hypertension, Child B cirrhosis, cardiac disease, chronic pulmonary disease, and renal failure. Patients undergoing robotic RH for donor hepatectomy were excluded. Fifteen reference values were derived from the 75th or the 25th percentile of the median values of all centers. Reference values were compared with a laparoscopic cohort from 4 centers and published benchmark values for laparoscopic and open RH. Results:Of 357 patients, 172 (48%) qualified as the benchmark cohort. The main indications were hepatocellular carcinoma (31%) and colorectal liver metastases (27%). Reference values included: operative time (≤476 min), conversion rate (≤8.2%), bile leak (≤15.4%), major complications (≤23.1%), and comprehensive complication index at 90 days (≤15.6). Robotic RH compared favorably to a multinational cohort series of laparoscopic RH with lower conversion (10.0% vs ≤8.2%) and R1 rate (10.9% vs ≤0%). Compared to open robotic hepatectomy, cutoffs for major complications (≤50.0% vs ≤23.1%) and liver failure (≤22.0% vs ≤2.7%) were lower for robotic right hepatectomies. Conclusion:This international benchmark study on robotic right hepatectomy (RRH) demonstrates that the robotic approach provides advantages compared with laparoscopic and open RH. RRH can be expected to become the minimally invasive approach of choice for tumors in the right liver.

Postoperative pancreatic fistula (POPF) remains the most severe complication following distal pancreatectomy (DP). The preoperative distal fistula risk score (D-FRS) was introduced to predict the POPF risk. The aim of this study was to externally validate the D-FRS in an international expert center cohort. This international, multicenter, retrospective cohort study included open and minimally invasive DP for benign and malignant lesions performed from 01/2014 until 12/2023 in 12 centres from 6 countries, that each performed more than 50 pancreatectomies annually. The D-FRS was calculated from pancreatic thickness and duct size. Predicted and actual POPF were compared using sensitivity, specificity and area under the curve (AUC). A total of 778 patients underwent DP of whom 284 (39

OBJECTIVE:The aim of this study was to identify risk factors for conversion and assess its consequences on clinical outcomes after robotic distal pancreatectomy (RPD). SUMMARY OF BACKGROUND DATA:RDP has gained popularity due to its lower conversion rate (3-8%) when compared to laparoscopic distal pancreatectomy (10-20%). METHODS:This retrospective multicenter study included RDPs performed at 16 international centers from May 2007 to March 2024. Perioperative outcomes of patients requiring conversion were compared to fully robotic RDP patients. Risk factors for conversion were identified by multivariable logistic regression analysis. RESULTS:Of 2,452 patients undergoing RDP, 75 (3.1%) required conversion to open surgery. In converted RDPs, operative time was longer (300 (243-376) vs. 180 (120-240) minutes; P<0.001), and blood loss was greater (500 (200-990) vs. 100 (50-200) ml; P<0.001). Converted patients experienced more overall complications (53% vs. 39%; P=0.017), major complications (41% vs. 25%; P<0.001), and a higher 90-day mortality (5% vs. 3%; P<0.001). Furthermore, both postoperative pancreatic fistula (35% vs. 18%; P<0.001) and delayed gastric emptying (10% vs. 3%; P<0.001) were more frequent in the conversion group. The rate of patients achieving textbook outcome was lower after conversion (57% vs. 74%; P=0.003). In the multivariable analysis, lesion size (>51 mm; OR 2.86 (95% CI 1.56-5.08)), BMI (>28 kg/m2; OR 3.03 (1.75-5.30)), previous abdominal surgery (OR 2.48 (1.31-4.51)), patients outside benchmark criteria (OR 2.09 (1.19-3.72)), and age (>62 years; OR 2.21 (1.24-4.05)) were associated with conversion. CONCLUSION:This international cohort study confirmed a very low conversion rate for RDP. Yet, converted cases experienced substantially impaired postoperative outcomes, highlighting the need for adequate patient selection through validated difficulty scoring systems.