**2.2 Liver mobilisation**

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 console and bed side surgeons.

### **2.3 Hilar dissection and hepatoduodenal clamping**

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 hepatectomy [10–12].

### **2.4 Parenchymal transection**

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

**15**

**Table 1.**

*Robotic Liver Surgery*

**2.5 Specimen extraction**

**3. Current evidence**

**3.1 Major resections**

**Author Year Total** 

Giulianotti et al.

Spampinato et al.

Fruscione et al.

**Cases**

Choi et al. 2012 20 RH (30%),

Wang et al. 2019 92 RH (48%),

2011 27 RH (74%),

2014 25 RH (64%),

2019 57 RH (35%),

*Clavien Dindo grades I-V. Mortality rate, 30 day post-operative mortality.*

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

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].

Major hepatectomies (resection of 3 or more contiguous segments) and extended hepatectomies with bile duct resections are complex, challenging procedures. High volume specialist centres have shown a minimally invasive approach to be feasible but the results from the only prospective randomised trial (ORANGE-II plus) are yet to be published [8, 10, 16]. At present, less than 10% of major liver resections are performed laparoscopically, largely due to the challenges posed by the location of the liver, its proximity to major vasculature and the difficulty in appreciating the complex biliary and hepatic vascular anatomy during a laparoscopic procedure [17]. Utilising a robotic approach may negate these disadvantages, with improved views and dexterity facilitating a precise hilar and hepatocaval dissection,

Specialised centres have published favourable outcomes (**Table 1**) and a limited number of multi centre comparative studies have demonstrated positive results [18–21]. A recent review of outcomes from 584 major robotic liver resections demonstrated acceptable blood loss, operation time, R0 resection rate, length of hospital stay and post op morbidity. When directly compared to laparoscopy, robotic major hepatectomies demonstrated significantly improved rates of post-operative

> **Conversion Rate**

NA – excluded from analysis

*RH, right hemi-hepatectomy; LH, left hemi-hepatectomy; RTS, right tri-sectionectomy; ERH, extended right hemihepatectomy; LLS, left lateral secitonectomy; SgVII, segment 6. Morbidity rate, includes post op complications from* 

**Length of stay**

3.7% 7 days 30% 0%

10% 15 days 40% 0%

4% 8 days 16% 0%

1% 7 days 13% 0%

**Morbidity Rate**

4 days 28% 0%

**Mortality Rate**

advanced suturing and easier biliary-enteric anastomosis.

**Specific procedures**

LH (19%), RTS (7%)

LH (70%)

LH (28%), ERH (4%), LLS + SgVI (4%)

LH (35%), other (30%)

LH (52%)

*Published series focused on outcomes following robotic major hepatectomies in the literature.*
