Robot-assisted laparoscopic hemi-hepatectomy: Technique and surgical outcomes
Eric C.H. Lai*, Chung Ngai Tang, Michael K.W. Li
Department of Surgery, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong SAR, China
a r t i c l e i n f o
Received 25 August 2011
Received in revised form
6 October 2011
Accepted 25 October 2011
Available online 3 November 2011
Laparoscopic liver resection
a b s t r a c t
Background: Laparoscopic major hepatectomies remain a challenge for liver surgeons. The recent
introduction of robotic surgical systems has revolutionized the field of minimally invasive surgery. It was
developed to overcome the disadvantages of conventional laparoscopic surgery. The use of robotic
system in laparoscopic major hepatectomy was not known yet.
Methods: Between December 2010 and July 2011, 6 right hemi-hepatectomies and 4 left hemi-
hepatectomies were performed by robot-assisted laparoscopic approach. Prospectively collected data
was analyzed retrospectively.
Results: Overall mean duration of the operation was 347.4 ? 85.9 (SD) minutes. Mean duration of the
operation for right hemi-hepatectomy was 364.8 ? 98.1 ml, while mean duration of the operation for left
hemi-hepatectomy was 321.3 ? 67.8 ml. Overall mean operative blood loss was 407 ? 286.8 ml. Mean
operative blood loss for right hemi-hepatectomy was 500 ? 303.3 ml, while mean operative blood loss
for left hemi-hepatectomy was 156.9 ? 40.7 ml. No open conversion was needed. Three patients (30%)
had postoperative complications. There was no mortality. Mean hospital stay was 6.7 ? 3.5 days.
Conclusions: Our series indicate that in experienced hands, robot-assisted laparoscopic approach for
hemi-hepatectomy is feasible and safe. As experience grows, this procedure will be more common.
? 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
The development of minimally invasive surgery over the last
two decades has had a great impact on surgical practice. Laparo-
scopic liver resection also becomes possible with the availability of
new instruments that allow a relatively bloodless liver transection.
The advantages of laparoscopic liver resection are those of mini-
mally invasive surgery, such as early recovery, shorter hospital stay,
and better cosmetic outcome.1e4The postoperative course after
laparoscopic liver resection has also become improved in patients
with cirrhosis because the abdominal wall is preserved, kinetics of
the diaphragm are improved, collateral venous drainage is better
and there is less postoperative ascites. Laparoscopy is generally
considered to be more suitable for minor hepatectomies in the
anterior and inferior segments.5An increasing number of laparo-
scopic major hepatectomy have only been reported by highly
specialized teams.6e8This is mainly because of concerns for tech-
nical difficulties of parenchymal transection, and difficulty in
controlling major hemorrhage via the laparoscopic approach.
Traditionally, laparoscopic liver resection can either be total
laparoscopic or hand-assisted laparoscopic approach. The recent
introduction of robotic surgical systems has revolutionized the field
of minimally invasive surgery. It was developed to overcome the
disadvantages of conventional laparoscopic surgery. The role of
robotic system in laparoscopic liver surgery has not been well
evaluated to date.9e11
The aim of the present cohort study was to study the clinical
outcome of robot-assisted laparoscopic hemi-hepatectomy.
2. Materials and methods
A prospective evaluation of robot-assisted laparoscopic liver resection was
initiatedin ourdepartment in 2009. Atthe end of 2010, westarted performing major
hepatectomy by robot-assisted laparoscopic surgery, including right and left hemi-
hepatectomies. The selection criteria for right and left hemi-hepatectomies were as
follows: tumor ? 6 cm in diameter, no major vascular invasion, non-cirrhotic liver or
Child-Pugh class A cirrhosis; and American Society of Anesthesiologists score
(ASA) ? 3. Patients were informed about the surgical procedure, and consent was
obtained before surgery. All procedures were performed by consultant surgeons
with expertise in hepatobiliary and laparoscopic surgery after obtaining informed
2.1. Patient positioning and port placement
The patient is placed in a supine positionwith legs apart. The patient is placed in
a 20?reverse Trendelenburg position. Five ports are generally used. They are
* Corresponding author. Tel.: þ86 852 2595 7123; fax: þ86 852 2515 3195.
E-mail address: email@example.com (E.C.H. Lai).
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1743-9191/$ e see front matter ? 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
International Journal of Surgery 10 (2012) 11e15
positioned along a semicircular arc facing the epigastrium (Fig. 1). The da Vinci?S
Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) was used for all robotic
assisted procedures. A 12-mm camera port, 12-mm operative port, and three
working 8-mm robotic ports were utilized. The abdominal cavity and liver are
assessed visually with a 30-degree telescope and with laparoscopic ultrasound. The
procedure then follows three stages: (1) portal dissection, (2) hepatic mobilization,
and (3) parenchymal transection. The robotic surgical system’s patient cart is placed
at the patient’s head for the docking phase. The first surgeon is seated at the robotic
console, while an assistant surgeon is positioned on the right side of the patient.
2.2. Step 1: portal dissection
The liver is retracted cephalad to expose the hilar region. The lesser omentum is
incised and a vascular tape is passed through the foramen of Winslow to surround
the hepatoduodenal pedicle. Although seldom necessary, this tape can be used for
Pringle maneuver during liver parenchymal transection.
2.2.1. Right hemi-hepatectomy (extraparenchymal dissection of the right portal
The right portal pedicle is dissected extraparenchymally. Cholecystectomy is
performed first. Starting from the junction of the cystic and common hepatic ducts,
the porta hepatis is dissected in a cephalad direction. Following the common hepatic
duct to the confluence of the right and left hepatic ducts, Glisson’s capsule is then
incised. The biliary confluence is retracted gently medially to expose the right
hepatic artery (Fig. 2), which is then transected between vascular clips. The portal
vein is mobilized up to the bifurcation of the right and left portal veins. The right
trunk is dissected and the left portalveinis clearly identified(Figs. 3 and 4). Theright
portal vein then is transected between vascular clips. Extrahepatic dissection of the
right bile duct is accomplished by lowering the hilar plate. The right bile duct is
divided during parenchymal transection (Fig. 5).
2.2.2. Left hemi-hepatectomy (extraparenchymal dissection of the left portal
The left portal pedicle is dissected extraparenchymally. The peritoneum of the
hepatic pedicle is incised in its left aspect and the left branch of the hepatic artery
and the left portal branch are dissected. The left branch of the hepatic artery is then
clipped and divided. The portal vein is mobilized up to the bifurcation of the right
and left portal veins. The left trunk is dissected and the right portal vein is clearly
identified. The left portal vein then is transected between vascular clips. Extrahe-
patic dissection of the left bile duct is accomplished by lowering the hilar plate. The
left bile duct is divided during parenchymal transection.
2.3. Step 2: hepatic mobilization
2.3.1. Right hemi-hepatectomy (mobilization of the right liver)
The right liver is freed from its attachments by cutting the falciform ligament,
right triangular and coronary ligaments, and the right liver is mobilized completely
from the right adrenal gland and retroperitoneum (Fig. 6). The inferior surface of the
liver is then lifted up using the fourth-arm instrument. The inferior vena cava is
dissected in a caudal tocephalad direction,working towardthehepatic veins (Fig. 7).
Small perforating vessels and accessory hepatic veins can be controlled with bipolar
coagulation or, in the case of larger vessels, surgical clips. The right hepatic vein is
2.3.2. Left hemi-hepatectomy (mobilization of the left liver)
The left liver is freed from its attachments bycutting the falciform ligament, and
the left triangular ligament. The anterior surfaces of the left hepatic vein and of the
middle hepatic vein are exposed.
2.4. Step 3: parenchymal transection
For those patients with good liver functional reserve, Pringle maneuver is
selectively used to apply intermittent vascular control to reduce blood loss from
contralateral side of the liver. If vascular control is required, the tension can be
tightened and retained as needed by clips. After these preliminary steps and
Fig. 1. Port site position.
Fig. 2. Dissection of right hepatic artery (RHA).
Fig. 3. Dissection of bifurcation of portal vein [main portal vein (MPV), right portal
vein (RPV), and left portal vein (LPV), common bile duct (CBD)].
E.C.H. Lai et al. / International Journal of Surgery 10 (2012) 11e15
provided the central venous pressure is optimal (<5 cm H2O), the capsule is incised
bycauterization before starting the transection, which begins on the anterior border
of the liver. Liver parenchymal transection following the line of demarcation along
the midplane of the liver is carried out using an ultrasonic dissector and diathermy
scissor (Fig. 8). The other two robotic arms can facilitate the transection by opening
up the operative site with liver retraction. The right hepatic vein (during right hemi-
hepatectomy) or left hepatic vein (during left hemi-hepatectomy) is divided inside
the parenchyma using a laparoscopic vascular stapler (Fig. 9). Application of either
a titanium clip or endostapler is used for the main vascular branches and bile ducts.
At the completion of the parenchymal transection, the raw surface is inspected for
any bile leak or oozing and such areas are plicated with 3/0 Monocryl (Ethicon,
Johnson & Johnson, Somerville, NJ, USA). An argon beam is also used to achieve
hemostasis from any oozing surface. The specimen is retrieved through a Pfannen-
stiel incision via an endobag.
2.5. Statistical method
Prospectively collected data, including intraoperative parameters, postoperative
complications, hospital mortality, and disease progress, were analyzed. Morbidity
and mortality were defined as occurring within 1 month of surgery. Continuous data
were expressed as the mean and standard deviation (SD).
Between December 2010 and July 2011, 10 hemi-hepatectomies
were performed by robot-assisted laparoscopic approach. Demo-
graphic characteristics of the patients and the operative results of
the robot-assistedlaparoscopichemi-hepatectomy were
summarized in Table 1. Overall mean duration of the operation was
347.4 ? 85.9 min. Mean duration of the operation for right hemi-
hepatectomy was 364.8 ? 98.1 min, while mean duration of the
operation for left hemi-hepatectomy was 321.3 ? 67.8 min. Overall
mean operative blood loss was 407 ?286.8 ml (range 100e600 ml).
Mean operative blood loss for right hemi-hepatectomy was
500 ? 303.3 ml, while mean operative blood loss for left hemi-
hepatectomy was 156.9 ? 40.7 ml. Just one patient with right
hemi-hepatectomy required perioperative
Extraparenchymal control and section of the portal pedicle were
achieved in all patients. No open conversion was needed. Three
patients (30%) had postoperative complications. Two bile leakages
occurred and were treated by controlled drainage with the intra-
operatively placed silicone drain. Both bile leakages resolved spon-
taneously. There was no mortality in our series. Mean hospital stay
was 6.7 ? 3.5 days.
Nine patients underwent operations for malignant tumors.
Mean size of resected tumors was 3.8 ? 1.6 cm (range,1e6 cm). Six
patients hade R0 resection, while 3 patients had R1 resection. Two
of these three patients with R1 resection had bilobarcolorectal liver
metastases, and the hemi-hepatectomies were combined with RFA
to manage the bilobar disease. At the time of censor, only one
patient had local recurrence. No port site or peritoneal metastases
were observed in patients with malignant pathologies.
Fig. 4. Dissection of right portal vein (RPV).
Fig. 5. Dissection of right hepatic duct (RHD).
Fig. 6. Excision of right coronary ligament.
Fig. 7. Hepatocaval dissection.
E.C.H. Lai et al. / International Journal of Surgery 10 (2012) 11e15
The first consensus meeting on laparoscopic liver surgery was
held in Louisville, Kentucky, in November 2008, incorporating the
opinions of the world’s experts in laparoscopic and open liver
surgery.5The organizing committee selected 45 recognized experts
from around the world with the most extensive published experi-
ence in both laparoscopic and open liver surgery. They concluded
that laparoscopic liver surgery is a safe and effective approach to
the management of surgical liver disease in the hands of trained
surgeons with experience in hepatobiliary and laparoscopic
surgery. Currently acceptable indications for laparoscopic liver
resection are patients with solitary lesions, 5 cm or less, located in
liver segments 2 to 6. The laparoscopic approach to left lateral
sectionectomy should be considered standard practice. Nguyen
et al. reviewed a total of 127 published articles of original series on
laparoscopic liver resection with 2804 reported minimally invasive
liver resections.12Fifty percent were for malignant tumors, 45%
were for benign lesions, 1.7% were for live donor hepatectomies,
and the rest were indeterminate. The most common laparoscopic
liver resection was a wedge resection or segmentectomy (45%)
followed by anatomic left lateral sectionectomy (20%), right hepa-
tectomy (9%), and left hepatectomy (7%). Conversion from lapa-
roscopy to open laparotomy and from laparoscopy to hand-assisted
approach occurred in 4.1% and 0.7% of reported cases, respectively.
Overall mortality was 0.3%, and morbidity was 10.5%, with no
intraoperative deaths reported. Studies have shown that in expe-
rienced hands, laparoscopic major hepatectomy is feasible and safe.
In the only comparative study of Dagher et al., 72 patients were
analyzed: 22 in the laparoscopic right hepatectomy group and 50 in
the open right hepatectomy group. Operating time was similar
(360.0 ? 20.3 vs. 328.0 ?10.6 min). Blood loss was significantly less
in laparoscopic resections (519.5 ? 93.4 vs. 735.2 ? 74.4 ml).
Specific morbidity rates were not different, general morbidity was
lower after laparoscopy and the severity of postsurgical complica-
tions was not different. Mean hospital stay was significantlyshorter
after laparoscopy (8.2 ? 1.1 vs. 12.5 ? 1.5 days). However, this
advanced technique was performed in only a few centers
worldwide.6e8Therefore, a reproducible technique minimizing the
risk at each stage of operation must be used if laparoscopy is to be
recommended for major hepatectomy.
Traditionally, laparoscopicliverresection can be performedwith
approach. Techniques of hand-assisted laparoscopic has been
attempted to bridge the gap between open and conventional total
laparoscopic approach. Obviously, total laparoscopic procedure is
superior to hand-assisted approach in terms of wound pain, and
cosmetic outcome as hand-assisted laparoscopic liver resection
usually required a 6e8 cm incision for the placement of the hand-
port. Another possible disadvantage of hand-assisted laparoscopic
approach includes possible obstruction of the visual field by the
surgeon’s hand during the operation. The recent introduction of
robotic surgical systems has revolutionized the field of minimally
invasive surgery. It was developed to overcome the disadvantages
of conventional laparoscopic surgery. Well-known advantages of
the robotic system such as improved vision via 3-dimensional view,
magnification, tremor suppression, and the flexibility of the
instruments have allowed precise operating techniques in a variety
of procedures in general surgery. The extrahepatic dissection of the
main branch of hepatic pedicle was considerably facilitated by the
magnification provided by robotic camera system and was there-
Fig. 8. Liver parenchyma dissection.
Fig. 9. Dissection of right hepatic vein (RHV).
Characteristics of patients and operative outcome.
CR liver metastases
Tumor size (cm)
Tumor with satellite nodules (n)
Associated procedures (n)
Operating time (mins)
Blood loss (ml)
Hand port conversion (n)
Open conversion (n)
Pringle maneuver (n)
Hospital stay (days)
Clear margins (n)
Microscopic positive margins (n)
M; F 5:5
65.1 ? 13.8
3.8 ? 1.6
347.4 ? 85.9
407 ? 286.8
6.7 ? 3.5
E.C.H. Lai et al. / International Journal of Surgery 10 (2012) 11e15
extraparenchymal dissection and selective control of the main
branch of hepatic pedicle were possible in all cases, without
intraoperative accidents. It is important to note that with this type
of advanced procedure, it is mandatory to have an experienced
assistant surgeonpresent. He can assist in suctioning and retracting
the tissue to obtain clear operative view. The main drawback of
advanced robotic surgery is the associated cost. Currently, the
experience with robotic surgery for partial hepatectomy reported
thus far in the literature remains limited.11,13e15
Based on our experience, major technical difficulties were
encountered for right hemi-hepatectomy. First of all, mobilization
of the right liver remains difficult and hazardous because of its large
volume and weight. Large tumors are certainly difficult to handle,
as they make mobilization of the right liver hazardous and increase
risk of inadvertent injury of the tumor or the adjacent parenchyma.
Therefore, great care should be taken to avoid injury of the liver,
tumor and inferior van cava throughout the whole procedure. For
this reason, patients with large and heavy right liver or large right
liver tumor were not suitable for robot-assisted laparoscopic
approach. The other difficulty of the laparoscopic approach is the
difficulty in maintaining proper 3-dimensional orientation of bulky
right hemi-liver. During resections for malignancy, the laparoscopic
ultrasound should be used to ensure that the proposed plane of
division will provide an adequate negative resection margin. For
parenchymal transection for hemi-hepatectomy, bleeding control
was a majorchallenge. In our experience, the Pringle maneuver was
used selectively to decrease the bleeding from the contralateral
side of the liver. This is particularly useful in cirrhotic liver.
In conclusion, the zero mortality and acceptable morbidity of our
approach for hemi-hepatectomy is feasible and safe. As experience
grows, this procedure will certainly become more common.
Conflict of interest
All the authors had no conflict of interest.
This study was not supported by any grant.
LECH contributed for the study design, data collection, data
analysis and writing.
TCN contributed for the study design, data analysis and proof
LMKW contributed for the study design, data analysis and proof
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