Right Hemihepatectomy, Robotically Assisted

• Positioning: Supine position with legs spread on a vacuum cushion. The cushion ensures stability, reducing the need for additional supports
• After trocar placement, the table is tilted to a 15° – 30° Anti-Trendelenburg position to optimize access
• Robot Docking:
  • The Xi system offers flexibility in the docking position, typically from the left
  • For X or Si systems, the cart is docked cranially from the right
• Team Positioning:
  • Surgeon: At the console, ideally with a view of the patient and assistant
  • Assistant: Positioned between the legs, sitting or standing
  • Scrub Nurse: On the right side of the patient
  • Anesthesiologist: At the patient’s head, on the right side

Pneumoperitoneum Creation:

• Use a Veress needle at the Palmer point in the left upper abdomen.
• Establish an insufflation pressure of 12–15 mmHg
• Alternatively, employ Optiview technique

Trocar Placement:

• Total Ports:
  • Four 8 mm robotic ports in a linear arrangement, 15–20 cm from the target anatomy (infraumbilical)
• Two 12 mm laparoscopic ports:
  • Assistant trocar (caudal between robotic ports 2 and 3)
  • Pringle maneuver trocar (caudal between robotic ports 1 and 2)
  • Spacing: Approximately 8 cm between each port
  • Position robotic trocars at the level of the muscular abdominal wall (aligning the broad black ring, the “Remote Center”)

Initial Instrument Configuration:

• Robotic ports (from right to left):
  • Port 1: Monopolar curved scissors
  • Port 2: Camera
  • Port 3: Bipolar forceps
  • Port 4: Prograsp forceps

  Docking the Robot:

• Dock the camera arm first (port 2)
• Execute Targeting (Xi system) to align robot arms with the surgical target
• Dock the remaining arms, ensuring 1 fist-width spacing between them
• Insert instruments under direct visualization via the assistant trocar

Key Precautions and Tips

Trocar Stability:

• Ensure the “Remote Center” aligns with the muscular abdominal wall to minimize shear forces during instrument movement

Instrument Placement:

• Use the assistant trocar and camera to inspect trocar alignment and verify instrument positioning before proceeding

Preventing Patient Movement:

• Double-check the vacuum cushion for leaks before sterile draping
• Secure arms during docking to avoid injury if the patient shifts

Control Checks:

• Before docking:
  • Mark trocar points and ensure proper spacing
  • Introduce the camera manually for inspection
• After docking:
  • Verify arm alignment and positioning of instruments

• Perform a small incision in the left upper abdomen for Veress needle placement
• Establish pneumoperitoneum at 15 mmHg
• Mark the trocar line and insert the first robotic trocar
• Insert the camera manually to confirm placement
• Sequentially place:
  • Three additional robotic trocars (8 mm)
  • Two laparoscopic trocars (12 mm) in the caudal positions
• Transition to Anti-Trendelenburg position (15°)
• Dock the camera arm and insert the camera
• Perform Targeting with the Xi system
• Dock the remaining three arms
• Insert instruments and park them at the target anatomy:
  • Port 1: Monopolar curved scissors
  • Port 2: Camera
  • Port 3: Bipolar forceps
  • Port 4: Prograsp forceps
• Inspect remote centers via the assistant trocar to ensure proper alignment

This systematic approach optimizes patient safety, instrument positioning, and robot utilization, ensuring precision in robotic-assisted right hemihepatectomy.

Adhesiolysis:

• Release adhesions between the omentum majus, gallbladder, and inferior liver surface
• Grasp the gallbladder fundus with the Prograsp Forceps and retract cranially
• Expose the entire gallbladder to the infundibulum

 Intraoperative Ultrasound:

• Insert the ultrasound probe through the assistant trocar
• Guide the probe with fenestrated bipolar forceps for precise movement
• Objective:
  • Visualize lesions and their relationship to vessels and bile ducts
  • Confirm the tumor-free status of the left liver lobe
  • Identify critical landmarks, including the middle hepatic vein and segmental branches to Segments V/VI and VIII

Marking the Resection Line:

• Using monopolar scissors, mark the resection line on the ventral liver capsule under ultrasound guidance

Create a window between the ligamentum teres and the abdominal wall

Gradually divide both ligaments with meticulous coagulation, progressing from caudal to cranial up to the diaphragm and coronary ligament

• Tip: Use the detached ligamentum teres as a traction point for atraumatic manipulation of the liver during the procedure

Incision and division of the anterior coronary ligament and exposure of the hepatic venous confluence with the entry of the hepatic veins into the inferior vena cava.

Access and Exposure:

• Elevate the liver using the Prograsp Forceps on the ligamentum teres
• Open the omentum minus over Segment I (Lobus caudatus)

 Cystic Structures:

• Identify and clip the cystic duct and cystic artery using the large clip applier
• Use ICG fluorescence imaging to confirm bile duct anatomy

Resection Line on Inferior Surface:

• Mark the resection line 1 cm lateral to the gallbladder bed on the inferior liver surface

Hepatic Structures:

• Identify:
  • Proper hepatic artery and its bifurcation into right and left branches
  • Right portal vein branch (and its anterior and posterior branches if present)
  • Dissect these structures using bipolar Maryland forceps, ensuring precision
  • Encircle major vessels with vessel loops for controlled manipulation

Right Hepatic Artery:

• Ligate and divide the right hepatic artery after ensuring appropriate demarcation of the right liver

Right Portal Vein:

• Ligate and divide the right portal vein branch using two proximal and one distal clip

Liver Mobilization:

• Elevate the Lobus caudatus and mobilize it by dividing connective tissue adhesions
• Sequentially expose and clip retrohepatic veins using Haemolock clips, progressing from caudal to cranial

Full Mobilization:

• Complete retrohepatic dissection, separating the right liver lobe from the Gerota’s fascia alongside the vena cava from caudal to cranial

In this case, the right hepatic artery was temporarily clamped using a bulldog vascular clamp to identify demarcation of the right liver. The bulldog clamp on the right hepatic artery was then released. A large clip applier was introduced through Port 1. The artery was transected between the clips. The loop was then transected and removed.

• Pass a Mersilene band through the foramen of Winslow (omentum foramen)
• Thread the band through a 12 Ch thoracic drain and extend it outside the abdomen via the laparoscopic trocar between robotic ports 1 and 2
• Ensure the band is long enough by knotting two bands together if necessary
• The Pringle maneuver can be activated by the table assistant to occlude hepatic blood flow when needed

Right Hepatic Artery Control:

• Initially clamp with a Bulldog vascular clamp to verify right lobe demarcation
• Clip and divide the artery using the large clip applier

Precautions and Tips:

• Ensure the common bile duct (DHC) is not compromised, especially in cases where the right hepatic artery passes beneath it—a common anatomical variant
• Sequentially verify vessel anatomy and use meticulous dissection to avoid unintended injury