Parenchymal Transection in Robotic Liver Surgery

Minimally invasive hepatic resections have become an increasingly accepted alternative for open hepatic resections, and robotic hepatectomy offers several advantages compared to laparoscopic approaches. However, there is currently no consensus on the preferred method for parenchymal transection in robotic hepatectomy. Several techniques/instruments have been described for parenchymal transection in robotic hepatectomy including the da Vinci harmonic ACE (“robotic harmonic”), cavitron ultrasonic surgical aspirator (CUSA) device, and robotic vessel sealer. Additionally, there are several robotic bipolar instruments used in conjunction to achieve hemostasis, dissection, and tissue transection. While hepatopancreaticobiliary (HPB) surgeons may develop a preference for one method/instrument, most case series describe successful robotic parenchymal transection using a combination of techniques (vessel sealer with bipolar cautery, harmonic scalpel with bipolar cautery, vessel sealer with harmonic scalpel, CUSA with bipolar cautery, etc.). Thus, as the frequency of robotic hepatectomy increases, it is important for HPB surgeons to gain familiarity with all methods of robotic parenchymal transection. The purpose of this chapter is to discuss the predominant methods/instruments used in robotic hepatic surgery worldwide, highlighting the advantages, disadvantages, and the technical aspects of each method.