Robotic right anterior sectionectomy with Glissonian approach

Robotic liver resection is one of the most complex procedures in hepatobiliary surgery. We have described a standardized technique for the Glissonian approach based on small incisions and following specific anatomical landmarks. It allows uncomplicated control of Glissonian pedicles without hilar dissection for both the right and left liver. This technique has been used in open and laparoscopic resections since 2001. This video demonstrates the technical aspects of a robotic right anterior sectionectomy using the Glissonian technique. In a 54-year-old man, a 1.6 cm tumor was discovered in the right liver during a routine examination. The MRI examination revealed that it was an inflammatory adenoma. However, during the follow-up examination, the tumor enlarged and became heterogeneous. MRI showed a heterogeneous hyperintense tumor on T2, with restricted water diffusion, diffuse and heterogeneous contrast enhancement in the arterial phase, which becomes hypointense in the hepatobiliary phase. The original diagnosis was an adenoma with malignant transformation. A right hepatectomy was proposed, but the future liver remnant was small and the patient had a fatty liver. The patient is morbidly obese and has already undergone bariatric surgery. Due to the characteristics of the liver and the size of the future liver remnant, the multidisciplinary team opted for a right anterior sectionectomy. A robotic approach was proposed and consent was obtained.

The robotic Glissonian approach is feasible and a useful technique for safe control of the right anterior pedicle, facilitating robotic right anterior sectionectomy. The main difference with the robotic approach is that we can easily encircle the pedicle in the same way as we have described for the open Glissonian approach. This maneuver is much more difficult with the laparoscopic approach and blind insertion of the clamp followed by the stapling device was the rule. The robotic approach allows a safer maneuver to reach the right anterior Glissonian pedicle while maintaining the minimally invasive technique. In summary, the robotic approach can help to perform liver resection with a minimally invasive technique, especially in more complex cases. The division of the liver following the ischemic area leads to less bleeding. This video shows the different steps required to perform this complex operation.