**2.5 Specimen extraction**

*Latest Developments in Medical Robotics Systems*

the time of docking.

**2.2 Liver mobilisation**

console and bed side surgeons.

hepatectomy [10–12].

**2.4 Parenchymal transection**

(i.e. stapling hepatic veins or hilar structures).

**2.3 Hilar dissection and hepatoduodenal clamping**

Following patient positioning and port insertion, the robotic cart is positioned within the surgical field and the arms docked. Traditional bed-side units are placed cephalic to the surgical field for most hepatobiliary and upper gastro-intestinal procedures. Newer versions allow the cart to be docked sideways to the patient. This adds the benefit of better access to the patient's airway for the anaesthetic team. Irrespective of the system, close collaboration with the anaesthetist is essential at

Following successful docking, the procedural steps are the same as for any hepatic resection and depend on the nature of the required procedure. Liver mobilisation is typically the first step and can be performed utilising a combination of a diathermy or an alternative energy device. For full mobilisation, all liver ligaments (Round/Falciform, Coronary and Triangular) need to be transected. Limited resections however, would not require full mobilisation. Traction and counter traction through lifting of the required liver lobes is provided with the combination of retractors and changes in the patient's position. This requires special attention if the operating table's movement are not linked to the robotic cart. New docking might be required. Lack of tactic feedback can lead to underestimation of the pressure applied to the liver with the consequent capsular tear. Alternatives will include a laparoscopic liver retractor manipulated by the bed side surgeon. Similarly, intraoperative ultrasound can be performed at this point with the close collaboration of the

Robotic surgery can overcome the limitations of laparoscopic surgery during complex hilar dissections, with the combination of 360 degrees angulation, 3D view and scaled movements providing significant advantages to the operator. The exact technicality of hilar dissection will again depend on the surgeon's experience and preferences. Some centres will routinely establish a window in the lesser omentum and pass a sloop or tape to facilitate a Pringle manoeuvre. Similarly to traditional LLS, this can be performed purely intracorporeally or extracorporeally (exteriorization of the clamp/tourniquet via an accessory port). However the high volume specialist centres have suggested this is not routinely required during robotic

There are multiple techniques for parenchymal transection and they are widely modified to the personal preferences of the operating surgeon. Kellyclasia technique (clamp-crushing) is held as the current gold standard, although recent advances have focused on the introduction of open and laparoscopic energy devices aimed at reducing blood loss during parenchymal division [13]. This crucial part of the operation is viewed as one of the limiting factors in the diffusion of MIS for the liver across hepatobiliary centres. Whilst robotic surgery improves the suturing capacity and bleeding control in difficult circumstances, the lack of an equivalent robotic energy device may require a hybrid approach with the assisting surgeon performing laparoscopic parenchymal transection at the operating table using an appropriate energy device [14]. Based on this principle, traditional laparoscopic instruments and stapling devices can be used similarly to the traditional laparoscopic approach

**14**

There is no difference between robotic and laparoscopic surgery at this point, with removal of the specimen via a retrieval bag is achieved following undocking of the robotic arms. Options for specimen extraction include extension of an existing port site or a new incision. There is little evidence comparing all available options but there seems to be a preference towards the Pfannestiel incision [15].
