Predictors of textbook outcome deviation in robotic liver resection: a single-center retrospective study.

PURPOSE: Textbook outcomes (TO) are composite indicators of surgical quality, but their role in robotic liver resection (RLR) remains unclear. This study aimed to define the TO in RLR and identify the preoperative predictors of TO deviation. METHODS: We retrospectively analyzed 94 patients who underwent RLR between September 2022 and January 2025. TO was defined as the absence of intraoperative incidents ≥ grade 2 (Oslo criteria), blood loss ≤ 370 mL, conversion, postoperative complications ≥ Clavien-Dindo grade II, prolonged hospital stay (> 14 days), and 30-day readmission. Multivariable analyses were performed using preoperative variables. RESULTS: TO was achieved in 79.8% (75/94) of the patients. The major causes of deviation included excessive blood loss, abscesses, pneumonia, and conversion. Advanced/expert IWATE criteria and mALBI grade ≥ IIa were independent predictors in one model (OR 6.1 and 4.8), whereas advanced/expert IWATE criteria and ALPlat ≤ 593 were predictors in another (OR 5.5 and 7.1). The composite score showed stepwise deviation rates of 4%, 9%, 36%, and 83%. CONCLUSIONS: TO in RLR is influenced by the liver function and the complexity of the procedure. Preoperative indices, such as the IWATE criteria, mALBI, and ALPlat, enable risk stratification and may support safer surgical planning.