V7. Optimizing Safety in Robotic-Assisted Right Hepatectomy: Technique for Complete Vascular Control of the Left and Middle Hepatic Veins Prior to Liver Transection

Robotic right hepatectomy remains a challenging procedure. The risk of bleeding from middle hepatic vein branches is one of the major technical challenges. We present the case of a robotic-assisted right hepatectomy with innovative intraoperative maneuvers to gain early and complete vascular control of the left and middle hepatic veins to minimize risk of intraoperative bleeding.


Methods:

A 71-year-old woman with colorectal adenocarcinoma presented with an isolated segment 7 hepatic metastasis involving the right hepatic vein. Following neoadjuvant chemotherapy, she underwent robotic-assisted right hepatectomy. Key operative maneuvers were employed to ensure safe vascular control including: (1) extrahepatic control of the left and middle hepatic veins, (2) intraoperative ultrasound guidance for vascular mapping, (3) indocyanine green (ICG) assessment of hepatic perfusion, and (4) intermittent Pringle maneuver application during parenchymal transection.


Results:

The caudate lobe was mobilized, and a plane was developed (Fig1A) between the inferior vena cava and the hepatic veins to allow vessel loop encirclement of the left and middle hepatic veins (Fig1B). This step provided a means for intermittent occlusion of the veins during liver transection to prevent venous back-bleeding. Intraoperative ultrasound confirmed tumor location and middle hepatic vein course (Fig1C). After ligation of the right hepatic artery and right hepatic vein, ICG assessment confirmed clear-cut demarcation of the right liver (Fig1D). The porta hepatis was then encircled with a 14-Fr catheter as a Huang loop Pringle maneuver (Fig1E). Parenchymal transection was performed under intermittent Pringle control with a saline-cooled double bipolar technique and intermittent tightening of the vessel loop to ensure complete venous control (Fig1F). Estimated blood loss from the case was 100mL, and the patient did not require any blood product transfusions. No bile leak was observed, and intraoperative ultrasound confirmed intact vascular inflow and outflow to the liver after resection.


Conclusions:

Robotic right hepatectomy with secure vascular control of the left and middle hepatic veins is feasible and safe in selected patients with colorectal liver metastasis. This case highlights the ability of a robotic platform to achieve complex vascular dissection and complete control of inflow and outflow vessels to allow for successful parenchymal transection while minimizing blood loss.