**2. Technique**

Robotic liver surgery has probably evolved from laparoscopic liver surgery and therefore it is easy to find some similarities. It is however a very different intervention, specially around the economy of movements, and it will vary significantly between centres and surgeons. Local expertise, surgeon's preferences and patient's specific conditions may modify the standard approach but there are some common principles. It is important to mention that currently all reported series have performed this type of intervention with the platform Da Vinci Robot from INTUITIVE® and some of the described technical aspect may apply only to this robotic system. New development of alternative robotic system may bring different technical concepts but the principles will prevail.

#### **2.1 Set up and docking**

There is significant overlap in the patient positioning, set up and operative technique between laparoscopic and robotic liver resections. This is commonly decided by the operating surgeon and based on his/her preferences. The main difference for a robotic approach is around port placement and the position of the "bed-side"/ assisting surgeon. It is essential to consider instrument clashing when deciding port placement. Alternatives to patient's position include supine (with or without split legs) or left prone position. The latter is the preferred position in some centres to intervene in right posterior segments. Ports position in laparoscopic surgery is more versatile whilst robotic surgery demands wider space between trocars without any port caudal or cephalic to another one (commonly smooth curved line or zig-zag) (**Figures 1**–**3**).

**13**

**Figure 3.**

**Figure 2.**

*transpyloric plane; 2, intertubercular plane.*

*Port placement for robotic major hepatectomy.*

*Robotic Liver Surgery*

**Figure 1.**

*resection (Figures 2 and 3).*

*DOI: http://dx.doi.org/10.5772/intechopen.99123*

*Patient (supine with split legs in a 15-0 degree reverse Trendelenburg) & assistant (between legs) positioning commonly utilised for major robotic hepatectomy. Subsequent camera and port placement depends on type of* 

*Patient positioning (left lateral decubitus) & port placement for robotic partial hepatectomy of posterosuperior segments. Rc, Robotic Camera Port; Ap, Assistant port (12mm); R1-3, Robotic ports (8-10 mm); 1,* 

#### **Figure 1.**

*Latest Developments in Medical Robotics Systems*

inherent limitations of laparoscopic surgery.

minor resections. From them, MIS for minor liver resections (less than 3 segments) such as left lateral secitonectomy and segmentectomies from the anterior Couinaud segments (II to VI) became well established [6]. On the contrary, there has been limited diffusion of minimally invasive major hepatectomies and it is commonly confined to high volume specialised centres [7]. This is in part due to the more complex anatomical and technical challenges of major hepatic resections, and the

Traditional laparoscopic surgery is the most commonly used MIS technique for liver resections whilst there is also an increment in the number of series of robotic liver surgery [8]. Advantages of robotic surgery when compared to traditional laparoscopic surgery are well described and include: a magnified three dimensional (3D) view, tremor filtration and improved dexterity with articulated instruments providing seven degrees of freedom [9]. It also adds some surgeon's specific advantages in terms of ergonomics with the suggested, but not proven, potential reduction of fatigue, increase precision and longer work expectancy. However controversies around robotic surgery remain when compared with laparoscopic surgery. Main limitation was always the higher cost without any evidence suggesting clinical superiority when compared to laparoscopic surgery. There is, in fact to date, lack of agreement whether they should be compared against each other, or directly compared to open surgery. We are of the opinion that both should be grouped as MIS and promoted equally for the benefit of the

In this chapter we describe the key aspects of robotic hepatobiliary surgery, with a focus on technical descriptions, the current evidence base, limitations, and

Robotic liver surgery has probably evolved from laparoscopic liver surgery and therefore it is easy to find some similarities. It is however a very different intervention, specially around the economy of movements, and it will vary significantly between centres and surgeons. Local expertise, surgeon's preferences and patient's specific conditions may modify the standard approach but there are some common principles. It is important to mention that currently all reported series have performed this type of intervention with the platform Da Vinci Robot from INTUITIVE® and some of the described technical aspect may apply only to this robotic system. New development of alternative robotic system may bring different

There is significant overlap in the patient positioning, set up and operative technique between laparoscopic and robotic liver resections. This is commonly decided by the operating surgeon and based on his/her preferences. The main difference for a robotic approach is around port placement and the position of the "bed-side"/ assisting surgeon. It is essential to consider instrument clashing when deciding port placement. Alternatives to patient's position include supine (with or without split legs) or left prone position. The latter is the preferred position in some centres to intervene in right posterior segments. Ports position in laparoscopic surgery is more versatile whilst robotic surgery demands wider space between trocars without any port caudal or cephalic to another one (commonly smooth curved line or zig-zag)

**12**

(**Figures 1**–**3**).

patient.

**2. Technique**

**2.1 Set up and docking**

possible future developments.

technical concepts but the principles will prevail.

*Patient (supine with split legs in a 15-0 degree reverse Trendelenburg) & assistant (between legs) positioning commonly utilised for major robotic hepatectomy. Subsequent camera and port placement depends on type of resection (Figures 2 and 3).*

**Figure 2.** *Port placement for robotic major hepatectomy.*

#### **Figure 3.**

*Patient positioning (left lateral decubitus) & port placement for robotic partial hepatectomy of posterosuperior segments. Rc, Robotic Camera Port; Ap, Assistant port (12mm); R1-3, Robotic ports (8-10 mm); 1, transpyloric plane; 2, intertubercular plane.*

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 the time of docking.
