Open, laparoscopic, and robotic liver resection for hepatocellular carcinoma: evolving roles, comparative outcomes, and future perspectives

Hepatocellular carcinoma remains one of the leading causes of cancer-related mortality worldwide and frequently arises in the setting of chronic liver disease, cirrhosis, and portal hypertension. Liver resection represents a cornerstone of curative-intent treatment, but its role is uniquely influenced by the need to balance oncologic radicality with preservation of functional liver parenchyma. Over the last two decades, minimally invasive liver surgery has progressively expanded from selected laparoscopic minor resections to complex laparoscopic and robotic hepatectomies, challenging the historical dominance of open surgery. This narrative review critically examines the evolving roles of open, laparoscopic, and robotic liver resection for hepatocellular carcinoma, emphasizing patient selection, technical considerations, scenario-based platform choice, and comparative outcomes. Particular attention is given to hepatocellular carcinoma-specific challenges, including impaired liver function, clinically significant portal hypertension, future liver remnant adequacy, recurrence risk, and the need for parenchymal-sparing strategies. The review also discusses distinct clinical scenarios, including small solitary tumors, posterosuperior lesions, central or deeply located tumors, multifocal disease, and recurrent HCC. Current evidence consistently suggests that minimally invasive approaches are associated with reduced blood loss, fewer postoperative complications, and shorter hospital stay compared with open surgery, while maintaining comparable oncologic outcomes in selected patients. Laparoscopy remains the most established minimally invasive platform, whereas robotics may offer technical advantages in complex resections through improved dexterity, three-dimensional visualization, and enhanced suturing capability. However, available evidence remains largely retrospective and influenced by selection bias and institutional expertise. Platform selection should therefore be individualized according to tumor anatomy, liver function, technical complexity, and center experience, with the goal of maximizing oncologic benefit while minimizing functional liver loss.