Robotic Partial Segment VIII Resection

Abstract

Background:

Robotic partial hepatectomy is an important tool for the treatment of colorectal liver metastases, offering the benefits of a minimally invasive approach with advanced wristed motion, precision, and dexterity. We demonstrate the steps of a robotic partial hepatectomy with specific emphasis on instruments, techniques, and the role of cross-sectional imaging and ultrasound in guiding a margin negative resection.

Patient:

A 66-year-old woman presented with a solitary segment VIII liver metastasis 5 years after laparoscopic right hemicolectomy for a T2N0M0 adenocarcinoma. After multidisciplinary tumor board discussion, the decision was made to proceed with resection of her oligometastatic disease following neoadjuvant chemotherapy.

Technique:

After laparoscopic entry and survey, the robotic platform was docked and ultrasound demonstrated the solitary metastatic lesion just anterior to the V8 branch of the middle hepatic vein; this would act as our deep margin. The liver was mobilized, a Rommel tourniquet using a 24-FR chest tube was placed around the porta hepatis, and the borders of resection were demarcated using the 1cm wide probe as a guide to ensure adequate margins. The capsule was incised and hepatic parenchyma divided with a bipolar energy device. After the first centimeter, a crush-clamp technique was used to safely identify larger structures that were ligated with endoscopic clips or vascular stapling devices. Immediate and final pathology confirmed widely clear margins.

Conclusion:

Robotic partial hepatectomy can be safely performed with the described technique. Reliance on cross-sectional imaging landmarks and liberal use of intraoperative ultrasound are helpful in achieving a R0 resection.