Robotic-assisted donor and recipient hepatectomy in liver transplantation: An umbrella review of clinical outcomes, surgical performance, and cost-effectiveness

Table 3 Recipients and economics (indirect evidence) - summary of findings and certainty (grading of recommendations assessment, development and evaluation): Recipients (indirect)

Outcome	Assumed risk (comparator per 1000)	Corresponding risk (robotic per 1000)	Effect, RR/MD; RD when available (95%CI)	Number of studies (participants)	Certainty (GRADE)	Notes
Conversion to open	RD pooled (no baseline required)	-50 per 1000	RR = 0.41 (0.32-0.52); RD = -0.05 (-0.07 to -0.03)	24 studies; participants NR	Low-moderate	1,3
Overall morbidity (any)	RD pooled (no baseline required)	-20 per 1000	RR = 0.92 (0.84-1.00); RD = -0.02 (-0.03 to 0.00)	20 studies; participants NR	Low	1,4
Severe morbidity (Clavien-Dindo ≥ III)	RD pooled (no baseline required)	-10 per 1000	RR = 0.81 (0.70, 0.94); RD ≈ -0.01	21 studies; participants NR	Low-moderate	1,3
Readmission	RD pooled (no baseline required)	+10 per 1000	RR = 1.24 (1.09, 1.41); RD = +0.01 (0.00, 0.01)	20 studies; participants NR	Low	1,2
30day mortality	Not estimable	Not estimable	RR = 0.77 (0.51, 1.15)	20 studies; participants NR	Low	1,4,5
Operative time (minutes)	N/A	N/A	MD = +8.8 (-4.8, 22) minutes	23 studies; participants NR	Low	1,2
Length of stay (days)	N/A	N/A	MD = -0.27 (-0.67, 0.12) days	26 studies; participants NR	Low	1,2

¹Indirectness: Recipient outcomes and all economic contrasts derive from non-transplant liver resections; downgraded for indirectness in grading of recommendations assessment, development and evaluation.

²Baseline risk: Absolute effects per 1000 are reported only when pooled baseline/comparator risks or pooled risk difference were available; otherwise reported as risk difference or “Not estimable”.

³Economics: Costs are taken verbatim from the network meta-analysis without re-standardizing baskets; interpret as hypothesis-generating for transplant settings.

⁴Context (not graded): MIOT meta-analysis and consensus guideline inform field context only and are not included in certainty ratings.

⁵Imprecision/inconsistency where applicable (e.g., mortality).

Table 3 (indirect): Robotic liver resection (RLR) vs laparoscopic/open. Heterogeneity: Extracted from Pilz da Cunha et al[22] and Koh et al[23]. Recipients (robotic vs laparoscopic resections): Overall morbidity I² = 24%; severe morbidity I² = 7%; 30-day mortality I² = 0%; operative time I² = 90%; length of stay I² = 41% (τ² not reported in the article text). Conversion: Number needed to treat ≈ 20; I² not reported in the article text/tables (likely in Supplementary material). Economics: The network meta-analysis reports comparative costs but does not provide standard I²/τ² for cost nodes; heterogeneity not estimable across cost categories. RR: Risk ratios; MD: Mean difference; GRADE: Grading of recommendations assessment, development and evaluation; RD: Risk difference; N/A: Not applicable; NR: Not reported.