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23 Robotic Cholecystectomy
303
We begin the dissection by opening the peritoneum over the junction of the
infundibulum with the cystic duct with hook cautery. The peritoneum reections
medial and lateral to the gallbladder are opened to provide better mobility and exposure, which facilitates a safer dissection. Once identied, the cystic duct and artery
are dissected clear with a combination of blunt dissection and electrocautery.
Complete dissection of the triangle of Calot is carefully performed until the critical
view of safety is achieved before clipping any structure (Fig.23.3).
Fluorescence cholangiography can additionally assist with delineating complex
biliary anatomy. Indocyanine green (ICG) is a tricarbocynanine dye that is excreted
through the biliary system, allowing for intraoperative visualization of biliary structures when visualized under infrared light (da Vinci Firey). ICG can be a tool for
visualizing biliary structures in complex cases (Fig.23.4).
Once this view is achieved, hook cautery is replaced with the large clip applier.
The cystic duct and artery are clipped twice. These structures are divided close to
the gallbladder with scissors or hook cautery. When using hook cautery, the structures should be under adequate tension and are divided using a cutting current with
the tip of the hook instrument. The gallbladder is then dissected off the hepatic fossa
with hook cautery. The gallbladder is typically removed through the umbilical site
in an endoscopic retrieval bag. Note, this incision may need to be extended to
remove the specimen and, therefore, is closed with 0-Vicryl on a suture passer.
If an intraoperative cholangiogram (IOC) is indicated to visualize biliary anatomy or uoroscopy is needed to perform transcystic common bile duct exploration,
a C-arm can be brought in from either side of the patient and positioned between the
robotic arms (Fig.23.5). The cystic duct is ligated proximally with a clip and a cystic ductotomy is made just distal. A 4-French cholangiocatheter is introduced into
the abdomen through a 14-gauge angiocatheter placed in the right upper quadrant.
The catheter is positioned into the cystic duct and secured with an 0-Vicryl tie.
Following completion of the IOC, the Vicryl is removed and two clips are placed
distal to the ductotomy prior to dividing.
ab
Fig. 23.3 Critical view of safety shown from the medial (a) and lateral (b) view of the hepatocys-
tic triangle
304
Fig. 23.4 Visualization of
biliary structures using
Firey
S. Cass et al.
Fig. 23.5 C-arm positioning during uoroscopy. The robotic arms are exed out laterally and the
C-arm is placed between arms 2 and 3
With the ability to detect common bile duct stones with intraoperative cholangiogram and uorescence cholangiography, robotic approaches to common duct explorations have been described and have been shown to be feasible and safe [13, 14].
For complex biliary disease, both transcystic and transcholedochal approaches with
balloon sphincteroplasty and cholangioscopy have been described. The robotic benets of added dexterity may allow for improved surgeon comfort with instrumentation and closure of the common bile duct, which with time may result in lower rates
of conversion to open procedures for complex biliary disease, though further studies
are needed to substantiate this. Additionally, the single-stage robotic approach to
choledocholithiasis with cholecystectomy and concomitant common bile duct
exploration has equivalent clearance rates to ERCP while decreasing total hospital
length of stay when compared to traditional two-stage management with cholecystectomy and ERCP [14].
23 Robotic Cholecystectomy
305
Single-Port Robotic Cholecystectomy
To reduce the trauma of multiport placement, single-port robotic cholecystectomy
(SPRC) was developed in 2011 and shown to be feasible [15, 16]. While its adoption has been limited due to the inherent ergonomic and technical challenges associated with single-site surgery, the safety of SPRC has been demonstrated.
A 2–3cm horizontal umbilical incision is made and deepened with cautery to
fascia. The fascia is opened horizontally and the peritoneum is entered. The da Vinci
single-site port is introduced; this system has ve openings for the camera, insufation tubing, two robotic instruments, and an assistant port. The 8mm camera trocar
is introduced following insufation and the PC is docked. Two robotic trocars are
introduced. Although these cross at the level of the fascia in order to provide triangulation of the gallbladder, the da Vinci software compensates by associating the
instrument tips with the ipsilateral surgeon controls. We use a fenestrated bipolar in
arm 1 and hook cautery in arm 2. The assistant port is placed and a grasper can be
introduced to lift the fundus of the gallbladder cephalad. Dissection is carried out in
similar fashion as with laparoscopic or multiport robotic cholecystectomy.
References
1. Sheetz KH, Clain J, Dimick JB.Trends in the adoption of robotic surgery for common surgical procedures. JAMA Netw Open. 2020;3(1):e1918911.
2. Stewart CL, etal. Common components of general surgery robotic educational programs. J
Surg Educ. 2023;80(11):1717–22.
3. Vidovszky TJ, etal. Robotic cholecystectomy: learning curve, advantages, and limitations. J
Surg Res. 2006;136(2):172–8.
4. Reynolds W.The rst laparoscopic cholecystectomy. JSLS. 2001;5(1):89–94.
5. Lujan JA, etal. Laparoscopic cholecystectomy vs open cholecystectomy in the treatment of
acute cholecystitis: a prospective study. Arch Surg. 1998;133(2):173–5.
6. Mannam R, etal. Laparoscopic cholecystectomy versus open cholecystectomy in acute cholecystitis: a literature review. Cureus. 2023;15(9):e45704.
7. Kane WJ, etal. Robotic compared with laparoscopic cholecystectomy: a propensity matched
analysis. Surgery. 2020;167(2):432–5.
8. Breitenstein S, etal. Robotic-assisted versus laparoscopic cholecystectomy: outcome and cost
analyses of a case-matched control study. Ann Surg. 2008;247(6):987–93.
9. Baek NH, etal. Short-term surgical outcomes and experience with 925 patients undergoing
robotic cholecystectomy during a 4-year period at a single institution. Hepato-Gastroenterology.
2015;62(139):573–6.
10. Straatman J, etal. Assessment of patient-reported outcome measures in the surgical treatment
of patients with gastric cancer. Surg Endosc. 2016;30(5):1920–9.
11. Kalata S, etal. Comparative safety of robotic-assisted vs laparoscopic cholecystectomy. JAMA
Surg. 2023;158(12):1303–10.
12. Townsend CM, etal. Sabiston textbook of surgery: the biological basis of modern surgical
practice. 20th ed. 2017; Philadelphia: Elsevier/Saunders. xxv, 2146 pages.
13. Latif J, etal. Robotic assisted common bile duct exploration for management of complex
gallstone disease. Int J Surg. 2024;
14. DeJesus J, Horani K, Brahmbhatt K, Mesa CF, Samreen S, Moffett JM.Conquering the common bile duct: outcomes in minimally invasive transcystic common bile duct exploration
306
versus ERCP. Surg Endosc. 2024. https://doi.org/10.1007/s00464- 024- 11228- 5. Epub ahead
of print. PMID: 39289226.
15. Hernandez, J.M., etal., Laparoendoscopic single site cholecystectomy: the rst 100 patients.
Am Surg. 2009;75(8): 681–5; discussion 685–6.
16. Hong TH, etal. Transumbilical single-port laparoscopic appendectomy (TUSPLA): scarless
intracorporeal appendectomy. J Laparoendosc Adv Surg Tech A. 2009;19(1):75–8.
S. Cass et al.
Liver Resection andBiliary
Reconstruction
YeeLeeCheah andCarolineJ.Simon
Introduction
Laparoscopic liver surgery has been performed since the 1990s, but an expansion of
laparoscopic techniques, particularly in major hepatectomy procedures, has been
restricted by limitations of the platform, including inadequate visualization,
restricted range of motion of laparoscopic instruments, and concerns regarding
intraoperative hemostasis during parenchymal transection [1, 2]. After the introduc-
tion of more sophisticated versions of the robotic platforms in the late 2000s, robotic
surgery has been gaining popularity as an alternative minimally invasive technique
for complex hepatobiliary and pancreatic surgery.
24
Robotic Liver Resection
Since the rst reported robotic liver resection in 2003, multiple centers with specialized programs have reported growing numbers of robotic hepatectomy [3].
Advantages of the robotic platform include wristed instrumentation, 3-D visualization, simultaneous multi-image display, and real-time indocyanine green (ICG)
uorescence to guide resection [4]. These benets allow meticulous dissection of
the liver hilum and application of hemostatic techniques familiar to an open liver
surgeon.
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 86927- 3_24.
Y. L. Cheah (*) · C. J. Simon
JC Walter Jr Transplant Center, Sherrie and Alan Conover Center for Liver Disease and
Transplantation, Houston Methodist Hospital, Houston, TX, USA
Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
e-mail: ycheah@houstonmethodist.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_24
307
308
The largest multicenter study comparing robotic to open liver resection for hepatocellular carcinoma with propensity score matching reported that patients who
underwent robotic surgery reported longer operative time but shorter hospital length
of stay and fewer admissions to the intensive care unit. There was no difference in
the overall and recurrence-related survival between the robotic and open groups, but
the robotic group had lower incidence of post-hepatectomy liver failure [5]. In terms
of oncological outcomes, robotic liver resection showed similar pathological outcomes, 3-year disease-free survival, and overall survival when compared to open
liver resection for hepatocellular carcinoma [6].
A worldwide meta-analysis of robotic liver resection outcomes comparing
robotic to laparoscopic or open liver resections revealed that overall robotic operative times were longer than laparoscopic or open cases. Overall complication rates
were also comparable between robotic and laparoscopic liver resections with shorter
length of hospital stays after robotic compared to open hepatectomy [7].
Y. L. Cheah and C. J. Simon
Patient Selection
There are no differences in the pathological indications for robotic versus open liver
resection. The preoperative workup includes the clinical assessment, cross- sectional
imaging (CT or MRI), and standard laboratory analysis, particularly liver biochemistry and function. Resectability and type of resection are determined by assessment of
liver function, liver quality (presence of damage from cirrhosis, metabolic dysfunction-associated fatty liver disease (MAFLD), or chemotherapy effect), local tumor
extent, and size of the future liver remnant. Occasionally, a focal liver biopsy of an
indeterminate mass may be necessary if it inuences treatment decisions, and a nonfocal biopsy may be necessary to rule out underlying liver disease or damage.
A decision to use a robotic approach should depend on the surgical team’s experience with the platform. It may be prudent to start with resection of the anterior and
lateral segments during the early part of a surgeon’s learning curve in robotic liver
surgery and progress to major hepatectomy and resection of the superior-posterior
segments after adequate experience is gained and good outcomes are achieved [8].
Patient factors such as previous laparotomy (particularly in the upper abdomen) or
previous liver resection may complicate a robotic approach but can be attempted
once competency with the platform is achieved [9]. Liver anesthesia management
with low central venous pressure is standard for both open and robotic approaches
[10]. Enhanced recovery protocols should be affected in appropriate patients when
indicated [11].
General Patient Positioning andPort Placement forLiver
andBiliary Surgery
Positioning
Patients are placed in a split-leg position to enable the bedside surgeon to stand
between the patient’s legs (Fig.24.1). All pressure points are padded. Arm(s) may
be abducted to enable access by anesthesiologist to intra-arterial and intravenous
24 Liver Resection andBiliary Reconstruction
309
Fig. 24.1 Robotic operating room setup
cannulas during the procedure. The patient is secured to the operating table at the
upper chest and hip levels. Both legs are secured to the leg extensions and footrests
are used to prevent slippage during positioning.
Port Placement
Figure 24.2 depicts the usual port placements for right-sided versus left-sided liver
resection, respectively. Both of these port positions work well for biliary surgery as
well. The placement of the camera provides adequate visualization of the right or left
side of the liver hilum as needed. The third arm is used for retraction and placed as a
right-handed instrument. Two laparoscopic assistant ports are placed in the lower
abdomen (12mm and 5mm). The liver specimen is usually extracted via a Pfannenstiel
incision whereas a choledochal cyst or bile duct segment may be extracted via the
12mm laparoscopic port. Pneumoperitoneum insufation pressure is kept at or below
12mm Hg to reduce the risk of air embolism through the hepatic veins.
Standard Robotic Instruments
1. Maryland bipolar (+ electrocautery).
2. Camera.
310
ab
Y. L. Cheah and C. J. Simon
Camera
3
1
Assistant
Fig. 24.2 (a) Port positioning for right-sided liver resection. (b) Port positioning for left-sided
liver resection
2
Assistant
Camera
1
Assistant
Assistant
3. Scissors (+ electrocautery).
4. Cadiere or Prograsp forceps.
5. Large needle driver.
6. Harmonic scalpel.
7. Small, medium, and large clip appliers.
8. Vessel sealer.
The detailed technique for two common types of major hepatectomy are
described below. All other minor and major hepatectomies should follow the basic
principles of hepatectomy, including inow +/− outow control followed by parenchymal transection. Pertinent tips on other types of hepatectomy are provided at the
end of the liver resection section.
3
2
Right Hepatectomy (see Video 1)
Falciform Dissection
The ligamentum teres and falciform ligamentum are divided with robotic scissors
using electrocautery up to the level of the hepatic vein-IVC conuence. The peritoneal covering of the hepatic vein conuence is incised, exposing the three hepatic
veins. For a standard right hepatectomy, the superior extent of the future transection
line is marked on the liver surface with electrocautery between the right and middle
hepatic veins (Fig.24.3).
24 Liver Resection andBiliary Reconstruction
Fig. 24.3 Conuence of
the hepatic veins and
superior extent of
transection line (dotted)
between right (RHV) and
middle (MHV) hepatic
veins
Fig. 24.4 Using the third
arm to retract segment 4
and cystic duct stump
exposing posterior aspect
of common bile duct
311
Hilar Dissection
The third arm is used to retract segment 4B and gallbladder anterosuperiorly; a
gauze is placed between the tip and elbow of the Cadiere/Prograsp to prevent injury
to the liver surface. The laparoscopic assistant retracts the duodenum inferiorly
with blunt-tipped instrument or suction device exposing the liver hilum. A standard
cholecystectomy is performed, and the gallbladder specimen is placed in Morrison’s
pouch for later removal. The clipped cystic duct stump is now ligated with a 3/0
Vicryl tie or suture-ligated with a 3/0 Vicryl suture with tails left long. The tails are
then grasped by the Cadiere/Prograsp positioned at segment 4B, and using the
forceps as a pulley, the cystic duct is retracted anteriorly and slightly to the patient’s
left, exposing the lateral and right posterior aspect of the common hepatic duct
(CHD) (Fig.24.4).
312
Y. L. Cheah and C. J. Simon
Dissection ofRight Hepatic Artery
The pulsation of a standard right hepatic artery (RHA) should be visible immediately behind the CHD at this stage. The lymphatic and nerve tissue lateral and posterior to the CHD are slowly dissected until the lateral wall of the artery is visualized.
If the artery is not found in this manner, a second method follows the clipped cystic
artery to its origin, which is usually the main or a branch of the right hepatic artery.
The posterior aspect of the standard RHA is loosely adherent to the anterior surface of the portal vein (PV) and the artery will need to be gently dissected off of the
PV (Fig. 24.5). Once the anterior, lateral, and posterior walls of the artery are
cleared, the tissues at the medial aspect of the RHA can be gently pushed away from
the arterial wall and the artery may be encircled with a vessel loop. Care is taken not
to injure the CHD and common bile duct (CBD), either via traction or cautery burn.
Alternatively, a replaced RHA from the superior mesenteric artery is usually
found lying posterior-laterally along the course CBD and CHD.In this position, the
artery is covered by a lymph node (Station 12b) that commonly stretches the right
lateral length of the bile duct. This node will need to be excised or displaced inferiorly to gain access to the replaced RHA.The main difference in dissection of a
replaced compared to a standard RHA is the close association of the length of the
artery to the portal vein posteriorly and CBD anterolaterally. The encircled RHA
can be divided between clips or ligatures.
Dissection ofRight Portal Vein
Division of the RHA will expose the anterior surface of the RPV, enabling access to
the portal vein bifurcation (Fig.24.6). The plane between the CHD and anterior surface of the PV is gently developed by pushing the portal vein posteriorly off the
attachments to the duct and RHA.Dissection proceeds cephalad until the bifurcation
is encountered. Clear identication of the bifurcation is conrmed by visualization of
the right, left, and main portal veins. The RPV anterosuperior surface is then carefully
Fig. 24.5 Right hepatic
artery noted between the
common hepatic duct
(CHD) and portal vein