Robotic versus laparoscopic liver resection for intrahepatic cholangiocarcinoma in elderly patients: a multicentre propensity-weighted analysis

Background Evidence comparing robotic and laparoscopic minimally invasive liver surgery (MILS) for intrahepatic cholangiocarcinoma (iCCA) in elderly patients remains limited. This study compared perioperative and oncological outcomes between the two approaches and identified factors associated with postoperative complications. Methods A multicentre retrospective study was conducted across 13 high-volume hepatobiliary centres including consecutive patients aged >= 70 years undergoing MILS for iCCA. Propensity score-based inverse probability of treatment weighting (IPTW) was applied. Perioperative, pathological, and survival outcomes were analyzed. Results A total of 272 patients were included (194 laparoscopic, 78 robotic). After IPTW adjustment, robotic surgery showed a trend toward lower overall postoperative complication rates (16.2 vs 30.9%; p = 0.050), significantly lower rates of severe complications (6.6 vs 11.0%; p = 0.027), shorter hospital stay (6.5 vs 8.7 days; p < 0.001), and lower conversion rates (3.8 vs 15.4%; p < 0.001). At multivariable analysis, robotic surgery remained independently associated with reduced postoperative morbidity (OR 0.47, 95% CI 0.30-0.73; p < 0.001), whereas higher IWATE difficulty score and conversion to open surgery were independently associated with postoperative complications. The robotic approach was also associated with a higher lymph node yield after IPTW adjustment (8.3 +/- 6.1 vs 5.4 +/- 4.6; p = 0.005), while disease-free and overall survival were comparable between groups during the available follow-up. Although 90-day mortality was higher in the robotic group, only five deaths occurred overall. Conclusions Robotic liver resection in elderly patients with iCCA was associated with improved short-term perioperative outcomes and lower conversion rates without evidence of inferior oncological outcomes. The higher 90-day mortality observed in the robotic group should be interpreted cautiously given the limited number of events. Operative complexity and conversion to open surgery were major determinants of postoperative morbidity.