The robotic-assisted left lateral hepatic segmentectomy: the next step

Introduction
The first laparoscopic hepatic resection was performed in 1992 by Gagner (1) and the first laparoscopic anatomic resection in 1996 by Azagra (2). In Romania, the first laparoscopic liver surgery was performed in 1998 in our center (3). Ever since, minimally invasive surgery had an astonishing development, progressing from minor hepatic interventions in the anterior segments of the liver to major hepatectomies, for both benign and malignant lesions (4, 5). This historical background is beneficial for the attempt to approach hepatic lesions with robotic equipment since the major advantages and pitfalls of the minimally invasive liver surgery are well known. Some of the classical limitations of laparoscopy are already avoided by the use of robotic systems that offer three-dimensional vision, enhanced dexterity and superior ergonomics (6).
Left lateral hepatic segmentectomy is the first anatomic hepatic resection on the learning curve in open and laparoscopic surgery (2, 7) therefore it is the recommendable start in performing robotic liver surgery.
Widely accepted indications of left lateral hepatic segmentectomy include benign lesions either cystic or solid such as hemangioma, focal nodular hyperplasia, adenoma, and malignant lesions such as hepatocellular carcinoma or liver metastases (4, 5, 8).
After our initial experience of 84 laparoscopic hepatic resections (8), we decided to start robotic liver surgery. The purpose of this report is to present the approach of liver segments II and III during left hepatic lobectomy using the DaVinci S robotic system and to demonstrate the feasibility and acceptability of this technique. To our knowledge this is the first report of this procedure’s technique.

Materials and Methods
Technical equipment
The interventions were performed with the aid of the three-arm DaVinci S robotic system (Intuitive Surgical Inc., Sunnyvale, CA) which consists of the surgeon console, the patient-side cart, the 3D-HD vision system and the Endo-Wrist® instruments. In our experience, the Harmonic curved shears was handled by the surgeon’s right hand and the Precise™ bipolar forceps or the fenestrated Maryland bipolar forceps by the left hand.
Personnel
The left lateral hepatic segmentectomy were perfomed by a single surgeon (I.P.), well experienced in hepatic surgery and laparoscopic surgery, recently trained in robotic surgery.
Bed-side assistants were surgeons trained in laparoscopic and robotic surgery. One scrubbed nurse and one operating room nurse were involved.
Patient selection
Preoperative abdominal and pelvic computer tomography (CT) were performed in all patients, in order to thoroughly describe the hepatic lesion and to rule out extrahepatic malignant disease. Chest x-ray was performed routinely. Blood samples for clinical biochemistry, tumoral and viral markers were collected and processed. Patients with previous upper abdominal surgery were excluded for these initial cases.
The study group consisted of three patients aged from 30-58 years, M:F=1:2. There were: one case of focal nodular hyperplasia (4/4,5/3 cm), one case of hepatocarcinoma (3/4/4 cm) developed on normal liver, one case of hemangioma (4/6/3 cm).

Results
Port and robotic cart placement
Before the intervention starts, the robotic system was turned on, draped and prepared. The 30º endoscope was calibrated.
The patient was placed in a supine position, in a 30º reverse Trendelenburg, with the limbs in adduction, and draped. The robotic cart was positioned with its axis coinciding with the working axis but coming from the opposite side. In robotic-assisted hepatic surgery, the cart approached from the right shoulder of the patient.
The robotic ports were placed approximately 10 cm apart in order to avoid the collision of the robotic arms (fig. 1). A 12 mm Hg pneumoperitoneum was created, with the insufflation through the camera port. The 12-mm camera port was placed above the ombillicus. Two 8-mm robotic ports were placed on both sides of the camera port, on the mid-clavicular line, in a slightly cephalad position (fig. 1). An additional 5-mm laparoscopic port was needed on the right subcostal side, on the anterior axilary line, for retraction, and a 10-mm port was needed on the left infraombilical side. This latter port was used for the LigaSure Atlas™ device (Tyco Healthcare, Valleylab, USA) or for the vascular stapler. A standard laparoscopic set was used for additional ports and instruments. Up to now, the preoperative diagnosis of the hepatic lesions was accurate therefore peroperative ultrasonography was not necessary but the equipment for this examination is available.
The two assistant surgeons were placed on the two sides of the patient.

Dissection
The trocar insertion and the robot docking were followed by the thorough inspection of the abdominal cavity and of the peritoneal surfaces. The lesions were identified and evaluated. The transsection of the liver parenchyma started on the left side of the falciform ligament and progressed on both liver surfaces (fig. 2). During the transsection, the pedicles for segments III and II were carefully identified, dissected and divised using the robotic instruments for dissection and the LigaSure Atlas™ device for division (fig. 3). In the final step of the transsection, the left hepatic vein was isolated and divised in the same manner. Then the left coronary and the left triangular ligaments were divised with the complete removal of the specimen from the remnant liver. Similar to laparoscopic liver bisegmentectomy, the Pringle maneuvre was not used.
The robotic arms were undocked and the intervention was completed laparoscopically by enhancing hemostasis and bilistasis using Argon plasma coagulation, hemostatic agents such as fibrin-coated collagen fleeces, oxidized regenerated cellulose materials, medicated sponges containing fibrinogen and thrombin. The specimen was inserted in an endo-bag which was extracted from the abdominal cavity through a minimal suprapubic incision. A drain was placed in the proximity of the hepatic section margin. Then, the suprapubic incision and the trocar sites were closed.
Postoperative course
In our experience, the operating time ranged between 120 to 160 minutes. The patients suffered minimal blood loss (between 70 to 150 ml), not requiring transfusion. The oral intake started 2 days after the intervention and the patients were discharged in the 7th postoperative day. So far, there were no conversions, reinterventions or postoperative mortality. The only postoperative complain was trocar-site pain reported by all patients.

Discussions
The patients with lesions that have indication of left lateral hepatic segmentectomy and no history of upper abdominal surgery are perfect candidates for robotic-assisted resections in the centers equipped with robotic systems. The performances achieved with the 3D-HD visual system, the seven degrees of motion of the robotic instruments that provide a good access in tight spaces, the motion scaling and tremor reduction properties, the restoration of hand-eye coordination and the superior ergonomics offered to the surgeon recommend the use of the robotic system in hepatic surgery. The easy access, the quick instrument exchange and undocking of the system further convinced the surgeons of the feasibility of robotic-assisted interventions in the proximity of important vessels (9-14).
In a center with a good experience of liver surgery and laparoscopic surgery (8), the robotic-assisted procedures are perceived as a natural evolution of the operative techniques in hepatic minimally invasive surgery. As in traditional liver laparoscopic resections, the starting point was the left lateral hepatic segmentectomy. The placement of the trocars was similar to that used in laparoscopy with a special attention to a minimal distance of 10 centimeters between port-sites. The use of Precise™ bipolar forceps or fenestrated Maryland bipolar forceps on the left hand and of the Harmonic curved shears on the right hand allowed the surgeon to perform a precise dissection, to accurately isolate the vascular pedicles for segments III and II and the left hepatic vein and to obtain a regular line in the hepatic section margin. However the use of LigaSure Atlas™ device on the vessel division was mandatory since the instruments adapted until now for robotic use do not offer the same security in sealing both the vessels and the biliary ducts. On the other side, superior dissection and visualisation of the left hepatic vein compared to traditional laparoscopy were observed which added more value to the safety of the robotic-assisted technique.
Similar to our protocol of laparoscopic II-III bisegmentectomy, we did not divise the falciform, left triangular and left coronary ligaments until the complete separation of the specimen from the remnant liver parenchyma since all these ligaments contribute to an adequate suspension of the left lobe throughout the entire procedure. Also, as previously reported (15), we did not use the Pringle maneuver in this procedure since the bleeding in the resection margin was due mainly to the affluents of the hepatic veins. A thorough hemostasis and bilistasis using all the efficient hemostatic agents and Argon plasma coagulation proved to be sufficient.
Even if rapid oral intake and intestinal motility restoration were observed, the patients were not immediately discharged because, similar to other series of patients undergoing newly introduced procedures, we needed a longer postoperative follow-up in order to observe all possible complications. However, since few complications were noticed, robotic surgery has the potential of becoming in time a cost-effective technique by easing the financial burden of postoperative care.
In conclusion, we report our technique of robotic-assisted left lateral hepatic segmentectomy as a reliable procedure based on a large experience of hepatic and minimally invasive surgery but also on a rapidly evolving new technology with many advantages over traditional laparoscopy. Therefore we believe that robotic II-III bisegmentectomy represents a feasible and applicable alternative in the treatment of corresponding hepatic lesions, potentially the next step in the field, but future large prospective studies will be needed in order to confirm the benefits of this technique.

References
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