When the robot bleeds: risk factors and outcomes of intraoperative blood loss in robotic liver resection

Background: Despite the advantages of robotic-assisted liver resection (RALR), intraoperative blood loss (IBL) remains a main concern in hepatic surgery. The current multicenter study was designed to evaluate the determinants of significant intraoperative bleeding in RALR and the clinical impact of such bleeding. Methods: This study retrospectively analyzed 708 consecutive RALR performed in nine high-volume European centers between 2011 and 2023. All demographic, intraoperative, and postoperative data were extracted from a shared database. Patients were stratified into two groups based on the IBL value (< 500 mL vs. ≥ 500 mL). Variables that reached the level of p < 0.10 at univariable analysis were included in a multivariate logistic regression model. Results: The mean IBL was 224.7 mL, and 9.6% of patients experienced IBL ≥ 500 mL. Both cirrhosis (OR 3.00, 95% CI 1.63–5.52; p < 0.001) and higher TAMPA score (OR 1.09 per point, 95% CI 1.03–1.16; p = 0.004) independently predicted major bleeding. Patients with IBL ≥ 500 mL had longer operative times (372 vs. 239 min, p < 0.001), higher morbidity (72% vs. 46%, p < 0.001), and greater mortality (4.4% vs. 0.6%, p = 0.022). Conclusions: During RALR significant bleeding persists in 10% of cases. Cirrhosis and procedural complexity remain independent predictors. Early identification of the high-risk patient and tailored perioperative strategies are of paramount importance in reducing bleeding and improving overall outcomes following robotic hepatobiliary surgery.