The operation begins with division of the round and falciform ligaments. Attachments between the liver and the hepatic flexure, right kidney, duodenum, or omentum are taken down using a hook electrocautery. The third robotic arm is positioned to provide upward and medial retraction to the right liver in order to explore the right triangular ligament laterally and short hepatic veins medially (Fig. 21.4). Appropriate adjustment is made by the third arm as the dissection proceeds cranially toward the hepatic hilum. The right side of the inferior vena cava (IVC) is dissected carefully off the inferior aspect of the liver. The short hepatic veins are individually isolated and divided between clips and silk ties.

Portal dissection is started by appropriately lifting the inferior aspect of the liver cranially using the third robotic arm. The gallbladder when still present can be used as a natural grasping handle by the third arm. The proper hepatic artery, which leads to the right hepatic artery, is identified. The right hepatic artery branch is isolated using a Maryland dissector and encircled with a vessel loop. A clamping test must be performed to ensure an intact arterial flow in the left hepatic artery prior to division. Silk tie with placement of metal clips or Hemolock clips are commonly used for this step (Fig. 21.5). A close attention must be exercised to avoid injury to the replaced or accessory right hepatic artery that is present in up to 25% of patients. The right portal vein is then carefully dissected and isolated prior to division using a linear vascular stapler (Fig. 21.6). Small branches to the caudate lobe often need to be divided in order to provide an adequate space for division. Finally the right hepatic duct is isolated, ligated, and divided after an intraoperative cholangiogram confirming presence of an intact contralateral biliary system (Fig. 21.7). Other authors have described the extra-Glissonian approach, where the right hepatic duct is divided using a linear stapler, without having to do a portal dissection with individual structure identification/ligation [2].

The right hepatic vein is then isolated and encircled with a vessel loop. A linear vascular stapler is used to divide the right hepatic vein by the bedside assistant, which safely accomplishes the outflow control. The line of parenchymal transection is then marked with the hook electrocautery, which follows a demarcation line on the liver surface. Placement of figure of eight silk sutures on both sides of the transection plane can be helpful for retraction (Fig. 21.8). Intraoperative ultrasonography is performed to confirm adequate tumor margins and to anticipate any large underlying crossing vessels. The Tilepro^® feature of da Vinci system is helpful in transferring the ultrasonographic images to the console. The liver parenchymal transection is started using a combination of a Maryland bipolar forceps, application of silk ties and metal clips, and the robotic vessel sealer device. Use of rubber bands for lateral traction of the liver in minimally invasive hepatectomy has been introduced by Choi et al. [18, 19]. As the parenchymal transection progresses, the traction of each rubber band was adjusted to optimize the exposure. The bedside assistant should help with tissue hemostasis and dynamic exposure of the transection plane. Medium- and large-sized crossing vessels/branches found intrahepatically are individually secured using ties and clips before division. Alternatively, they can also be handled using linear vascular stapler, fired by the bedside assistant. Thorough hemostasis and meticulous search for bile leak are performed along the cut surface prior to placing an abdominal drain. The resected specimen is placed in a large endo bag retrieval system and removed via either the enlarged camera port at the umbilical location or via a Pfannenstiel incision.

The round and falciform ligaments are taken using similar technique as the right liver resection. A complete stomach decompression via a naso/oro-gastric tube is important at the beginning of the case. The left triangular ligament is divided using the hook electrocautery. It is important to not injury the branch of the phrenic veins often located nearby. Access into the lesser sac is obtained by dividing the gastrohepatic ligament. An accessory or replaced left hepatic artery is ligated and clipped prior to division when present in about 10–15% of patients. The lesser sac is opened all the way cephalad, toward the origin of the left hepatic vein. The goal is to obtain a complete mobilization of the left hemiliver. The portal dissection and parenchymal transection are performed using similar techniques as the right liver resection. The transverse portion of the left portal inflow allows a technically safer dissection. The right posterior sectoral bile duct empties into the left hepatic duct in approximately 13–19% of the population [20, 21]. Therefore, it is safer to divide the left bile duct close to the junction of the transverse and umbilical portion of the portal pedicles. Outflow dissection is subsequently performed after division of Arentius’ ligament. With the left lobe reflected toward the right, the origin of the left and middle hepatic veins is carefully dissected. In majority of patients, the left and middle hepatic veins create a common trunk before entering the inferior vena cava. A linear vascular stapler is used to divide the hepatic vein after encirclement using a vessel loop (Fig. 21.9). If a safe outflow dissection cannot be achieved extrahepatically, the hepatic veins can also be divided intra-hepatically as the parenchymal transection proceeds cephalad (Fig. 21.10). Hemostasis and bilestasis are meticulously ensured prior to completion.

In a left lateral sectionectomy, the transection line is located just to the left of the falciform ligament after left hemiliver mobilization. The divided round ligament can be used as a handle toward the right anterior direction, which opens up the transection plane. Segment 2 and 3 pedicles were taken (either together or individually) with vascular load linear staplers, following the extra-Glissonian technique. The parenchymal transection is performed using similar steps, similar to those in formal left or right hepatectomies. Crossing vessels to segment 4A and 4B usually are usually encountered, but they can be easily managed with clips, vessel sealing devices, or linear staplers. The left hepatic vein is divided intrahepatically toward the end of the parenchymal transection. For nonanatomic liver resection, intraoperative ultrasonography is frequently used to ensure adequate margins and to detect underlying major vessels to and from the segments of pathology. Adequate planning for vascular control of medium/large vessel branches shown by the ultrasound should be in place prior to transection. Complete hemostasis and detection of bile leak must be ensured after parenchymal division. When a bile leak is identified from a biliary branch, careful placement of silk or vicryl sutures are effective. For hemostasis, we prefer to use saline-cooled radiofrequency device, which gives excellent results. Thermal energy, however, must be carefully applied in areas near the hepatic hilum and vessel staple lines. It is a good practice to lower the pneumoperitoneum while observing the liver cut surface for occult bleeding prior to closure [22].

It is critical to have a skilled bedside assistant surgeon with this type of advanced operations in liver surgery. Intraoperative bleeding during parenchymal transection is the primary reason for conversion to open surgery during major laparoscopic liver resection. Similar situation applies for major robotic liver resections. Conversion rates in laparoscopic major hepatectomy range from 33% in the early experience by Dulucq et al. [23] to a lower rate of 14% reported more recently by Gayet et al. [24]. In the totally robotic right hepatectomy of 24 patients reported by Giulianotti et al. [25], open conversion only occurred in 1/24 patients, which was related to oncologic concerns (inability to carefully evaluate the resection margins).

Robotic application in hepatobiliary surgery has included complex biliary tract reconstructive operations for benign and malignant biliary pathology. In 1995, the first report of minimally invasive choledochal cyst excision with Roux-en-Y hepaticoenterostomy was published by Farello et al. [22]. Unfortunately, adoption of this technique is slow, because of its technical complexity. In the past 5 years, however, several studies have emerged due to the availability of robotic system in many developed countries, which clearly facilitates performance of complex minimally invasive biliary tract operations [26, 27]. Alizai et al. reported 27 total cases of robot-assisted resection of choledochal cysts with hepaticojejunostomy in children, with five cases converted to open because of technical difficulties [28]. Reported average operative time was 5 h. Positive outcomes after 2.7 years of mean follow-up were reported with one child developed anastomotic stricture and subsequent bile leak after an open redo hepaticojejunostomy. Median hospital stay was 6 days and cosmetic results were excellent. Another report of robot-assisted complete excision of type 1 choledochal cyst with significantly shorter operative time (180 min) was published by Akaraviputh et al. [29]. A postoperative complication, which required percutaneous drainage of fluid collection and administration of systemic antibiotic, was noted, with otherwise excellent 1 year follow-up outcomes.