Written informed consent has been obtained from the patient to use medical data and the operative video for education and scientific purposes. This research was performed in compliance with all institutional, national, and international guidelines for human welfare.
1. Positioning and robot docking
<ol>
	<li>Position the patient on a vacuum mattress in a supine French position. Lower the right arm alongside the body on an arm support and extend the left arm. Tilt the operating table 10-20&#176; in anti-Trendelenburg and 5-10&#176; to the right.</li>
	<li>After all safety procedures (hood, sterile glove, and sterile scrub) are ascertained, create a sterile exposition. Make a 2 mm incision in the left hypochondrium on the midclavicular line and create a pneumoperitoneum with CO2 to 15 mmHg by placing a Veress needle.</li>
	<li>Insert the robotic camera through a visiport 12 mm trocar in the right pararectal space just below the umbilicus and perform a diagnostic laparoscopy. Once diagnostic laparoscopy confirms no contraindication for surgery, place the remaining trocars as shown in Figure 2.
	<ol>
		<li>Place four 8 mm trocars above the umbilicus and introduce a 12 mm laparoscopic assistant trocar for the bedside surgeon on the right side of the umbilicus.</li>
		<li>Ensure that the bedside surgeon can reach the transection area for suctioning, compression, clipping, and stapling without difficulty. The distance between the four ventral trocars is approximately 8 cm.</li>
	</ol>
	</li>
	<li>Place the robot on the right side next to the patient and dock the arms to the four robotic trocars.</li>
	<li>Ensure that the first surgeon takes place at the robot console and the bedside surgeon between the patient&#39;s legs.</li>
</ol>
2. Mobilization
<ol>
	<li>Start with the mobilization of the left lobe. Divide the round and falciform ligaments using the robotic cautery hook and vessel sealer.</li>
	<li>Then, continue the mobilization by dividing the left coronary and triangular ligaments using the robotic cautery hook and/or vessel sealer. 
	NOTE: It is important not to injure the left hepatic vein and branches of the phrenic vein, often located nearby and draining into the left hepatic vein.</li>
	<li>Open the triangular ligament using the robotic cautery hook and/or vessel sealer all the way toward the origin of the left hepatic vein. Dissection is completed until the origin of the left hepatic vein is reached.</li>
	<li>Visualize the lesser omentum by lifting the inferior aspect of the liver cranially. Dissect the lesser omentum using a vessel sealer. 
	&#8203;NOTE: If an aberrant left hepatic artery is present, ligate using the robotic cautery hook and/or vessel sealer.</li>
</ol>
3. Hilar dissection
<ol>
	<li>Identify the proper and left hepatic artery in the hepatoduodenal ligament by lifting the liver cranially and moving the robotic camera to the hilum.</li>
	<li>Dissect and isolate the left hepatic artery using both the robotic cautery hook and bipolar forceps (optional: Maryland bipolar forceps).</li>
	<li>After visualizing the left hepatic artery, identify and dissect the origin of the right hepatic artery to make sure it is preserved.</li>
	<li>Then, dissect and isolate the left portal vein carefully. Switch the view to ICG-fluorescence imaging to identify the exact localization and trajectory of the left bile duct with respect to the left portal vein. 
	&#8203;NOTE: ICG was administered preoperatively in parallel to induction of general anesthesia prior to the start of the surgery.</li>
</ol>
4. Cholecystectomy
<ol>
	<li>Identify the cystic duct and artery.</li>
	<li>First, dissect and isolate the cystic duct and artery using the robotic cautery hook to achieve the critical view of safety, also known as the Calot&#39;s Triangle.</li>
	<li>Clip both cystic duct and artery using polymer locking clips. Place two clips proximally and one distally on the cystic duct. Place one clip proximally and one clip distally for the cystic artery.</li>
	<li>Divide the cystic duct and artery between the clips with robotic scissors.</li>
	<li>Second, dissect the gallbladder circumferentially off the liver using a robotic cautery hook until the gallbladder is detached from the liver.</li>
	<li>Place the resected gallbladder in an extraction bag and position it outside of the working field.</li>
</ol>
5. Vascular transection
<ol>
	<li>Prepare a pringle loop by passing a vessel loop around the hepatoduodenal ligament. During this procedure, the pringle maneuver was not applied.</li>
	<li>Perform an intraoperative ultrasound (IOUS) of the liver to confirm the localization, borders, and depth of the biliary cyst.</li>
	<li>Switch the view to ICG-fluorescence imaging to confirm the trajectory of the right and left hepatic duct before heading to the arterial and venous hilar transection.</li>
	<li>First, clip the left hepatic artery carefully with polymer locking clips by placing two clips proximally and one distally.</li>
	<li>Divide the left hepatic artery between the clips with robotic scissors.</li>
	<li>Pass a vessel loop around the left portal vein using the Maryland bipolar forceps to ensure isolation of the left portal vein with preservation of the segment 1 branch.</li>
	<li>Then, clip the left portal vein with polymer locking clips by placing two clips proximally and one distally.</li>
	<li>Divide the left portal vein between the clips with robotic scissors. 
	&#8203;NOTE: The left hepatic bile duct is not divided during this phase of the procedure to ensure no injury to the right hepatic duct.</li>
</ol>
6. Parenchymal transection
<ol>
	<li>Visualize the ischemia line on the liver surface. The ischemia line should overlap the Cantlie&#39;s line since the aim is to perform anatomical left hepatectomy. Mark the transection line following the ischemia line using a cautery hook.</li>
	<li>Perform the superficial part of the transection using a cautery hook until a depth of 1 cm parenchyma is reached. For the deeper parenchyma, use the vessel sealer, the cautery spatula, and Maryland bipolar forceps.</li>
	<li>Control intrahepatic vascular and biliary structures with the vessel sealer as well. Control any intrahepatic small bleeding using the cautery spatula or bipolar forceps. Now carefully identify the branch of the middle hepatic vein for preservation.</li>
	<li>Transect the parenchyma until the left hepatic vein is reached. Before completion of the parenchymal transection, move back to the hilum to focus on the left hepatic duct.</li>
	<li>Switch the view to ICG-fluorescence imaging to confirm the exact trajectory, size, and localization of the left hepatic duct.</li>
	<li>Dissect the left hepatic duct carefully using the Maryland bipolar forceps.</li>
	<li>At last, clip the left hepatic duct with polymer locking clips by placing one clip proximally and one clip distally. Divide the left hepatic duct between the clips with robotic scissors. The procedure ends with the division of the left hepatic vein.</li>
	<li>Pass a vessel loop around the remaining liver parenchyma and left hepatic vein for the hanging maneuver. 
	NOTE: This allows retraction of the right lobe of the liver toward the right side and puts tension on the remaining liver parenchyma and left hepatic vein to be able to get a better vision and grip on the left hepatic vein.</li>
	<li>Then, divide the left hepatic vein using a laparoscopic stapler.</li>
	<li>After completion of the left hepatectomy, place the resected specimen in an extraction bag and take both the specimen and gallbladder out through a Pfannenstiel incision. No intra-abdominal drain was placed.</li>
</ol>

<ol>
	<li>Jab&#322;o&#324;ska, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Biliary+cysts:+Etiology,+diagnosis+and+management.">Biliary cysts: Etiology, diagnosis and management.</a> World Journal of Gastroenterology. 18 (35), 4801-4810 (2012).</li><li>Singham, J., Yoshida, E. M., Scudamore, C. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Choledochal+cysts+part+1+of+3:+Classification+and+pathogenesis.">Choledochal cysts part 1 of 3: Classification and pathogenesis.</a> Canadian Journal of Surgery. 52 (5), 434-440 (2009).</li><li>Todani, T., Watanabe, Y., Narusue, M., Tabuchi, K., Okajima, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Congenital+bile+duct+cysts.+Classification,+operative+procedures,+and+review+of+thirty-seven+cases+including+cancer+arising+from+choledochal+cyst.">Congenital bile duct cysts. Classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst.</a> American Journal of Surgery. 134 (2), 263-269 (1977).</li><li>Tsuchiya, R., Harada, N., Ito, T., Furukawa, M., Yoshihiro, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Malignant+tumors+in+choledochal+cysts.">Malignant tumors in choledochal cysts.</a> Annals of Surgery. 186 (1), 22-28 (1977).</li><li>Jan, Y. Y., Chen, H. M., Chen, M. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Malignancy+in+choledochal+cysts.">Malignancy in choledochal cysts.</a> Hepatogastroenterology. 47 (32), 337-340 (2000).</li><li>Okada, A., Hasegawa, T., Oguchi, Y., Nakamura, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Recent+advances+in+pathophysiology+and+surgical+treatment+of+congenital+dilatation+of+the+bile+duct.">Recent advances in pathophysiology and surgical treatment of congenital dilatation of the bile duct.</a> Journal of Hepato-Biliary-Pancreatic Surgery. 9 (3), 342-351 (2002).</li><li>Nicholl, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Choledochal+cysts+in+western+adults:+Complexities+compared+to+children.">Choledochal cysts in western adults: Complexities compared to children.</a> Journal of Gastrointestinal Surgery. 8 (3), 245-252 (2004).</li><li>Singham, J., Yoshida, E. M., Scudamore, C. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Choledochal+cysts:+Part+3+of+3:+Management.">Choledochal cysts: Part 3 of 3: Management.</a> Canadian Journal of Surgery. 53 (1), 51 (2010).</li><li>vander Poel, M. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Implementation+and+outcome+of+minor+and+major+minimally+invasive+liver+surgery+in+the+Netherlands.">Implementation and outcome of minor and major minimally invasive liver surgery in the Netherlands.</a> HPB. 21 (12), 1734-1743 (2019).</li><li>Ciria, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+systematic+review+and+meta-analysis+comparing+the+short-+and+long-term+outcomes+for+laparoscopic+and+open+liver+resections+for+hepatocellular+carcinoma:+Updated+results+from+the+European+guidelines+meeting+on+laparoscopic+liver+surgery,+Southampton,+UK,+2017.">A systematic review and meta-analysis comparing the short- and long-term outcomes for laparoscopic and open liver resections for hepatocellular carcinoma: Updated results from the European guidelines meeting on laparoscopic liver surgery, Southampton, UK, 2017.</a> Annals of Surgical Oncology. 26 (1), 252-263 (2017).</li><li>Nota, C. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+laparoscopic+liver+resection:+a+systematic+review+and+pooled+analysis+of+minor+and+major+hepatectomies.">Robot-assisted laparoscopic liver resection: a systematic review and pooled analysis of minor and major hepatectomies.</a> HPB. 18 (2), 113-120 (2016).</li><li>Nota, C., Molenaar, I. Q., Hagendoorn, J., Borel Rinkes, I. H. M., van Hillegersberg, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+laparoscopic+liver+resection:+First+dutch+experience.">Robot-assisted laparoscopic liver resection: First dutch experience.</a> HPB. 18 (1), 265 (2016).</li><li>Alkhalili, E., Berber, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+liver+resection+for+malignancy:+a+review+of+the+literature.">Laparoscopic liver resection for malignancy: a review of the literature.</a> World Journal of Gastroenterology. 20 (37), 13599-13606 (2014).</li><li>Cai, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+between+robotic-assisted+and+laparoscopic+left+hemi-hepatectomy.">Comparison between robotic-assisted and laparoscopic left hemi-hepatectomy.</a> Asian Journal of Surgery. 45 (1), 265-268 (2021).</li><li>Troisi, R. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+approach+to+the+liver:+Open+surgery+in+a+closed+abdomen+or+laparoscopic+surgery+with+technical+constraints.">Robotic approach to the liver: Open surgery in a closed abdomen or laparoscopic surgery with technical constraints.</a> Surgical Oncology. 33, 239-248 (2019).</li><li>Sucandy, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+hepatectomy+for+benign+and+malignant+liver+tumors.">Robotic hepatectomy for benign and malignant liver tumors.</a> Journal of Robotic Surgery. 14 (1), 75-80 (2020).</li><li>Beard, R. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+and+oncologic+outcomes+of+robotic+versus+laparoscopic+liver+resection+for+metastatic+colorectal+cancer:+A+multicenter,+propensity+score+matching+analysis.">Long-term and oncologic outcomes of robotic versus laparoscopic liver resection for metastatic colorectal cancer: A multicenter, propensity score matching analysis.</a> World Journal of Surgery. 44 (3), 887-895 (2020).</li><li>Wang, J. -. M., Li, J. -. F., Yuan, G. -. D., He, S. -. Q. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+versus+laparoscopic+minor+hepatectomy:+A+systematic+review+and+meta-analysis.">Robot-assisted versus laparoscopic minor hepatectomy: A systematic review and meta-analysis.</a> Medicine (Baltimore). 100 (17), 25648 (2021).</li><li>Ciria, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+impact+of+robotics+in+liver+surgery:+A+worldwide+systematic+review+and+short-term+outcomes+meta-analysis+on+2,728+cases.">The impact of robotics in liver surgery: A worldwide systematic review and short-term outcomes meta-analysis on 2,728 cases.</a> Journal of Hepatobiliary Pancreatic Sciences. 29 (2), 181-197 (2020).</li><li>Wong, D. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+review+and+meta-analysis+of+robotic+versus+open+hepatectomy.">Systematic review and meta-analysis of robotic versus open hepatectomy.</a> ANZ Journal of Surgery. 89 (3), 165-170 (2019).</li><li>Strasberg, S. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Nomenclature+of+hepatic+anatomy+and+resections:+A+review+of+the+Brisbane+2000+system.">Nomenclature of hepatic anatomy and resections: A review of the Brisbane 2000 system.</a> Journal of Hepato-Biliary-Pancreatic Surgery. 12 (5), 351-355 (2005).</li><li>Sucandy, I., Gravetz, A., Ross, S., Rosemurgy, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique+of+robotic+left+hepatectomy+how+we+approach+it.">Technique of robotic left hepatectomy how we approach it.</a> Journal of Robotic Surgery. 13 (2), 201-207 (2019).</li><li>Magistri, P., Assirati, G., Ballarin, R., Di Sandro, S., Di Benedetto, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Major+robotic+hepatectomies:+technical+considerations.">Major robotic hepatectomies: technical considerations.</a> Updates in Surgery. 73 (3), 989-997 (2021).</li><li>Fruscione, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+versus+laparoscopic+major+liver+resection:+analysis+of+outcomes+from+a+single+center.">Robotic-assisted versus laparoscopic major liver resection: analysis of outcomes from a single center.</a> Hpb. 21 (7), 906-911 (2019).</li><li>Ka&#231;maz, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+enucleation+of+an+intra-pancreatic+insulinoma+in+the+pancreatic+head.">Robotic enucleation of an intra-pancreatic insulinoma in the pancreatic head.</a> Journal of Visualized Experiments:JoVE. (155), e60290 (2020).</li><li>Shah, A. J., Callaway, M., Thomas, M. G., Finch-Jones, M. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Contrast-enhanced+intraoperative+ultrasound+improves+detection+of+liver+metastases+during+surgery+for+primary+colorectal+cancer.">Contrast-enhanced intraoperative ultrasound improves detection of liver metastases during surgery for primary colorectal cancer.</a> HPB. 12 (3), 181-187 (2010).</li><li>Bijlstra, O. D., Achterberg, F. B., Grosheide, L., Vahrmeijer, A. L., Swijnenburg, R. -. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fluorescence-guided+minimally-invasive+surgery+for+colorectal+liver+metastases,+a+systematic+review.">Fluorescence-guided minimally-invasive surgery for colorectal liver metastases, a systematic review.</a> Laparoscopic Surgery. 5, (2021).</li><li>Handgraaf, H. J. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+follow-up+after+near-infrared+fluorescence-guided+resection+of+colorectal+liver+metastases:+A+retrospective+multicenter+analysis.">Long-term follow-up after near-infrared fluorescence-guided resection of colorectal liver metastases: A retrospective multicenter analysis.</a> European Journal of Surgical Oncology. 43 (8), 1463-1471 (2017).</li><li>Vahrmeijer, A. L., Hutteman, M., Van Der Vorst, J. R., Van De Velde, C. J. H., Frangioni, J. V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Image-guided+cancer+surgery+using+near-infrared+fluorescence.">Image-guided cancer surgery using near-infrared fluorescence.</a> Nature Reviews. Clinical Oncology. 10 (9), 507-518 (2013).</li><li>Van Der Vorst, J. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Near-infrared+fluorescence-guided+resection+of+colorectal+liver+metastases.">Near-infrared fluorescence-guided resection of colorectal liver metastases.</a> Cancer. 119 (18), 3411-3418 (2013).</li><li>Eeson, G., Karanicolas, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemostasis+and+hepatic+surgery.">Hemostasis and hepatic surgery.</a> The Surgical Clinics of North America. 96 (2), 219-228 (2016).</li><li>Otsuka, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=What+is+the+best+technique+in+parenchymal+transection+in+laparoscopic+liver+resection?+Comprehensive+review+for+the+clinical+question+on+the+2nd+International+Consensus+Conference+on+Laparoscopic+Liver+Resection.">What is the best technique in parenchymal transection in laparoscopic liver resection? Comprehensive review for the clinical question on the 2nd International Consensus Conference on Laparoscopic Liver Resection.</a> Journal of Hepato-Biliary-Pancreatic Sciences. 22 (5), 363-370 (2015).</li><li>Hawksworth, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Improving+safety+of+robotic+major+hepatectomy+with+extrahepatic+inflow+control+and+laparoscopic+CUSA+parenchymal+transection:+technical+description+and+initial+experience.">Improving safety of robotic major hepatectomy with extrahepatic inflow control and laparoscopic CUSA parenchymal transection: technical description and initial experience.</a> Surgical Endoscopy. 36 (5), 3270-3276 (2021).</li><li>Zwart, M. J. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pan-European+survey+on+the+implementation+of+robotic+and+laparoscopic+minimally+invasive+liver+surgery.">Pan-European survey on the implementation of robotic and laparoscopic minimally invasive liver surgery.</a> HPB. 24 (3), 322-331 (2021).</li><li>Fruscione, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+versus+laparoscopic+major+liver+resection:+analysis+of+outcomes+from+a+single+center.">Robotic-assisted versus laparoscopic major liver resection: analysis of outcomes from a single center.</a> HPB. 21 (7), 906-911 (2019).</li><li>Cipriani, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pure+laparoscopic+versus+robotic+liver+resections:+Multicentric+propensity+score-based+analysis+with+stratification+according+to+difficulty+scores.">Pure laparoscopic versus robotic liver resections: Multicentric propensity score-based analysis with stratification according to difficulty scores.</a> Journal of Hepato-Biliary-Pancreatic Sciences. , (2021).</li><li>Coletta, D., Sandri, G. B. L., Giuliani, G., Guerra, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+versus+conventional+laparoscopic+major+hepatectomies:+Systematic+review+with+meta-analysis.">Robot-assisted versus conventional laparoscopic major hepatectomies: Systematic review with meta-analysis.</a> The International Journal of Medical Robotics + Computer Assisted Surgery. 17 (3), 2218 (2021).</li></ol>

The authors have nothing to disclose.

The use of robotic major MILS has increased gradually over the years for both benign and malignant indications. However, robotic major left hepatectomy is still a technically demanding procedure and it is, therefore, suggested to follow a structured approach, including six main steps: positioning and docking of the robotic system, mobilization of the left lobe, hilar dissection, cholecystectomy, vascular transection, and parenchymal transection.
ICG-fluorescence imaging is emerging as a promising and useful tool during robotic liver surgery as applied in the current procedure. While IOUS is routinely performed during robotic MILS and provides the most actual information on number and size of lesions, and its relation to anatomical structures26, it may be technically challenging due to limitations in free-range of motion and lack of information on precise biliary tract anatomy27. ICG-fluorescence imaging can, therefore, aid the surgeon in both visualizing liver lesions and the exact trajectory of intra- and extrahepatic biliary ducts to perform an uncomplicated robotic liver resection. Previously published retrospective studies on ICG-fluorescence imaging during liver surgery primarily focused on the sensitivity of ICG-fluorescence imaging and detection of additional liver lesions as compared to IOUS rather than focusing on the intra- and postoperative impact of enhanced intraoperative visualization of biliary tract anatomy28,29,30. These studies showed that significantly more additional lesions were identified in patients where ICG-imaging was performed compared to IOUS with comparable intra- and postoperative outcomes between both groups. Of note, these studies didn&#39;t include robotic MILS.
Parenchymal transection is one of the most critical steps during robotic MILS and accounts for the majority of blood loss, being a major determinant of morbidity and mortality. A careful and structured approach with the use of appropriate robotic instruments is therefore necessary. Transection techniques have evolved over time from the clamp-crush technique to the use of a variety of energy devices31,32. Ultrasonic dissection devices such as the Cavitron Ultrasonic Aspirator (CUSA) offer superior visualization of intrahepatic structures and are often used during parenchymal transection32. However, the laparoscopic CUSA is the only available ultrasonic dissection device successfully integrated into laparoscopic MILS, not available for robotic MILS33,34. During the current robotic procedure, a cautery hook was used for the superficial part of the liver and both the vessel sealer and the cautery spatula for the deeper parenchyma. Of note, a recent survey study highlighted that 70% of the surgeons performing robotic MILS were dissatisfied with the available robotic instruments for liver parenchymal transection34. The development of new instruments for robotic parenchymal transection might help to further improve outcomes after liver surgery and increase the adoption of robotic MILS.
Blood loss, operative time, and length of hospital stay of the current procedure were favorable and comparable with recent series on major robotic MILS22,23. Furthermore, the robotic procedure has similar intra- and postoperative outcomes as compared to laparoscopic MILS35,36. However, it is important to emphasize that robotic MILS is costly and more challenging as compared to the laparoscopic and open approach. Specific training in robotic MILS in combination with extensive experience in both open and laparoscopic liver surgery is needed to perform robotic MILS safely37. We therefore believe that robotic major MILS such as a robotic left hepatectomy should be limited to high-volume MILS centers and a careful selection of patients should be applied.
In summary, this manuscript provides the detailed steps of a robotic left hepatectomy, as performed at Amsterdam UMC in the Netherlands. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging may be helpful in delineating BC and bile duct anatomy. Further comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract1. Approximately 1% of all benign biliary diseases are BC with an incidence of 1:1000 in Asian countries and 1:100,000 to 1:150,000 in western countries1,2. While the majority of cases are diagnosed during infancy or childhood, 20% of the cases are diagnosed in adults2. BC are divided into groups as per the Todani classification3. The early diagnosis and treatment are crucial since BC are associated with a risk of carcinogenesis, not only occurring more often in these patients but also 10-15 years before the disease is manifested4,5,6. The overall risk of malignancy has been reported to be 10%-15%, and depends on the Todani classification and age1,6. While patients aged 31-50 years with BC have a risk of 19% of carcinogenesis, 51-70-year-old patients with BC were reported to have a risk of at least 50% of carcinogenesis7. Surgery is the cornerstone treatment of BC8. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection or liver transplantation in case of bilobar Todani V8.
In recent years, minimally invasive liver surgery (MILS), including laparoscopic and robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications9,10,11,12. According to the most recent international Southampton guidelines on laparoscopic liver surgery, laparoscopy is now seen as the gold standard for minor liver resections and laparoscopic major liver resections are considered feasible and safe in selected patients if performed by surgeons who have completed the learning curve for minor laparoscopic liver surgery. However, laparoscopic liver surgery has some persistent limitations, including restriction of movements, presence of physiologic tremors and reduced visualization13,14. Robotic MILS is, therefore, a valuable alternative to laparoscopic MILS. It is suggested that robotic MILS provides a better magnified three-dimensional view, tremor filtration, improved dexterity with several degrees of freedom, ease of suturing, and better motion scaling, as compared to laparoscopic liver surgery15,16,17. Furthermore, robotic MILS allows the surgeon to remain in a seated posture, reducing fatigue during surgery18. While some studies reported on the potential advantages of robotic MILS as compared to open liver surgery, several high-volume expert centers showed similar outcomes of both minor and major robotic and laparoscopic MILS14,18,19,20. However, major robotic MILS, defined as the resection of three or more Couinaud&#39;s segments21, is still considered technically demanding and a detailed description of the technical approach during robotic major MILS had only been discussed limitedly in the literature. Studies describing the technique and use of robotic MILS for the treatment of BC Todani Type V are lacking.
Here, we describe our robotic technique of a left hepatectomy using Indocyanine green (ICG) fluorescence imaging for a symptomatic complex BC. This case involves a 68-year-old woman who had elevated liver enzymes during a routine check-up without any clinical symptoms. An abdominal ultrasound of the liver revealed intrahepatic dilatation of the biliary ducts specifically in the left hemi liver without a clear lesion. Further diagnostic examinations, including an abdominal CT scan, MRI scan, (Figure 1) and MRCP, showed a large intrahepatic complex cystic lesion of 40 mm on the border of segment 4a and 4b in continuity with the biliary tree with intrahepatic dilatation of biliary ducts in the left lobe. The patient was diagnosed with a large BC Todani Type V of the left hepatic duct and was recommended for a robotic left hepatectomy. Since there were no signs of biliary obstruction, preoperative biliary drainage was not performed.

<table><tbody><tr><td>&lt;em&gt;Systems&lt;/em&gt;</td><td></td><td></td><td></td></tr><tr><td>Arietta V70 Ultrasound</td><td>Hitachi</td><td>-</td><td>The ultrasound system.</td></tr><tr><td>da Vinci Surgeon Console</td><td>IS</td><td>SS999</td><td>Used to control the surgical robot.</td></tr><tr><td>da Vinci Vision Cart</td><td>IS</td><td>VS999</td><td>The vision cart houses advanced vision and energy technologies and provides communications across da Vinci system components.</td></tr><tr><td>da Vinci Xi</td><td>IS</td><td>K131861</td><td>The surgical robot: &amp;rsquo;patient side-cart&amp;rsquo;.</td></tr><tr><td>Robotic ultrasonography transducer</td><td>Hitachi</td><td>L43K</td><td>Used for intraoperative laparoscopic ultrasonography.</td></tr><tr><td>&lt;em&gt;Instruments&lt;/em&gt;</td><td></td><td></td><td></td></tr><tr><td>da Vinci Xi Endoscope with Camera, 8 mm, 30?</td><td>IS</td><td>470027</td><td>The camera of the da Vinci robot.</td></tr><tr><td>EndoWrist Fenestrated Bipolar Forceps</td><td>IS</td><td>470205</td><td>Used for dissection and coagulation.</td></tr><tr><td>EndoWrist HOT SHEARS</td><td>IS</td><td>470179</td><td>Used for cutting and coagulation.</td></tr><tr><td>EndoWrist Maryland Bipolar Forceps</td><td>IS</td><td>470172</td><td>Used for dissection.</td></tr><tr><td>EndoWrist Permanent Cautery Hook</td><td>IS</td><td>470183</td><td>Used for coagulation.</td></tr><tr><td>EndoWrist Medium-Large Clip Applier</td><td>IS</td><td>470327</td><td>Used for clipping with Weck Hem-o-lok medium-large polymer clip</td></tr><tr><td>EndoWrist Stapler 45 Instrument</td><td>IS</td><td>470298</td><td>Used for stappling</td></tr><tr><td>Vessel sealer</td><td>IS</td><td>480322</td><td>Used for vessel sealing and dividing.</td></tr></tbody></table>

robotic left hepatectomy using indocyanine green fluorescence imaging for an intrahepatic complex biliary cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Representative results are shown in Table 1. Following the surgical technique in the protocol, the operative time was 189 min with an intraoperative blood loss of 10 mL. No conversion to laparotomy was needed and no intraoperative incidents occurred. The postoperative course was uncomplicated without any postoperative complications. The patient was discharged on postoperative day 4.
The final histopathological examination revealed a large complex cyst of 3.1 cm in continuity with a biliary branch of the left hepatic duct without any suspicion for malignancy.
Comparable result from literature 
Several studies investigated outcomes of major robotic liver surgery, including robotic left hepatectomy22,23,24. An operative time of 383 min (IQR 240-580 min)23 with an estimated intraoperative blood loss of 300 mL (IQR 100-1,000)23 has been described previously. With regards to postoperative outcomes, a length of hospital stay of 3 days (IQR 3-5 days)22,24, a favorable Clavien-Dindo &#8805; grade III complication rate of 7.0%24 and a remarkable low mortality rate (0%)22,23,24 were reported.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63265/63265fig01.jpg" /> 
Figure 1: The appearance of the biliary cyst and the relationship with the left biliary tree on MRI-scan <a href="https://www.jove.com/files/ftp_upload/63265/63265fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/63265/63265fig02.jpg" /> 
Figure 2: Trocar placement. R1: robotic trocar at right anterior axillary line; R2: robotic trocar at right mid-clavicular line; R3: robotic trocar on midline; R4: robotic trocar at left mid-clavicular line. L1: laparoscopic assistant trocar on the right side of the umbilicus. This figure is adapted from Ka&#231;maz, E. et al. 202025. <a href="https://www.jove.com/files/ftp_upload/63265/63265fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Variable</td>
			<td>Outcome</td>
		</tr>
		<tr>
			<td colspan="2">Intraoperative</td>
		</tr>
		<tr>
			<td>Operative time (min)</td>
			<td>189</td>
		</tr>
		<tr>
			<td>Conversion to laparotomy</td>
			<td>No</td>
		</tr>
		<tr>
			<td>Estimated intraoperative blood loss (mL)</td>
			<td>10</td>
		</tr>
		<tr>
			<td>Intraoperative incidents</td>
			<td>No</td>
		</tr>
		<tr>
			<td colspan="2">Postoperative</td>
		</tr>
		<tr>
			<td>Clavien-Dindo complication</td>
			<td>No</td>
		</tr>
		<tr>
			<td>Clavien-Dindo complication &#8805; grade III</td>
			<td>No</td>
		</tr>
		<tr>
			<td>90-day Reoperation</td>
			<td>No</td>
		</tr>
		<tr>
			<td>Length of hospital stay, days</td>
			<td>4</td>
		</tr>
		<tr>
			<td>90-day readmission</td>
			<td>No</td>
		</tr>
		<tr>
			<td>90-day/in-hospital mortality</td>
			<td>No</td>
		</tr>
		<tr>
			<td>Pathological diagnosis</td>
			<td>Large complex biliary cyst without malignancy</td>
		</tr>
	</tbody>
</table>
Table 1: Outcome of the surgery

Watch this Scientific Journal Video about Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst at JoVE.com

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

robotic-left-hepatectomy-using-indocyanine-green-fluorescence-imaging

Research

JoVE Journal

Medicine

5.5K Views.  Amsterdam UMC, location University of Amsterdam. Robotische linker hepatectomie met behulp van indocyanine groene fluorescentie beeldvorming voor een intrahepatisch complex galcyste. In dit geval gaat het om een 68-jarige vrouw die verhoogde leverenzymen had tijdens een routinecontrole zonder klinische symptomen. Een abdominale echografie van de lever onthulde intrahepatische dilatatie van de galwegen beperkt tot de linker hemi-lever zonder een duidelijke laesie.Verdere diagnostische onderzoeken, waaronder een abdominale CT, MRI-scan...

Video: Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

An Investigation of the Effects of Sports-related Concussion in Youth Using Functional Magnetic Resonance Imaging and the Head Impact Telemetry System

One of the most commonly reported injuries in children who participate in sports is concussion or mild traumatic brain injury (mTBI)1. Children and youth involved in organized sports such as competitive hockey are nearly six times more likely to suffer a severe concussion compared to children involved in other leisure physical activities2. While the most common cognitive sequelae of mTBI appear similar for children and adults, the recovery profile and breadth of consequences in children remains largely unknown2, as does the influence of pre-injury characteristics (e.g. gender) and injury details (e.g. magnitude and direction of impact) on long-term outcomes. Competitive sports, such as hockey, allow the rare opportunity to utilize a pre-post design to obtain pre-injury data before concussion occurs on youth characteristics and functioning and to relate this to outcome following injury. Our primary goals are to refine pediatric concussion diagnosis and management based on research evidence that is specific to children and youth. To do this we use new, multi-modal and integrative approaches that will:
 1.Evaluate the immediate effects of head trauma in youth 
2.Monitor the resolution of post-concussion symptoms (PCS) and cognitive performance during recovery 
3.Utilize new methods to verify brain injury and recovery
To achieve our goals, we have implemented the Head Impact Telemetry (HIT) System. (Simbex; Lebanon, NH, USA). This system equips commercially available Easton S9 hockey helmets (Easton-Bell Sports; Van Nuys, CA, USA) with single-axis accelerometers designed to measure real-time head accelerations during contact sport participation 3 - 5. By using telemetric technology, the magnitude of acceleration and location of all head impacts during sport participation can be objectively detected and recorded. We also use functional magnetic resonance imaging (fMRI) to localize and assess changes in neural activity specifically in the medial temporal and frontal lobes during the performance of cognitive tasks, since those are the cerebral regions most sensitive to concussive head injury 6. Finally, we are acquiring structural imaging data sensitive to damage in brain white matter.

This article provides an overview of a multi-modal approach to mild traumatic brain injury diagnosis and recovery in youth. This approach combines neuropsychological testing with functional magnetic resonance imaging and the Head Impact Telemetry System to monitor the relationship between head impacts and brain activity during cognitive testing.

One of the most commonly reported injuries in children who participate in sports is concussion or mild traumatic brain injury (mTBI)1. Children and youth ...

3-Dimensional Resin Casting and Imaging of Mouse Portal Vein or Intrahepatic Bile Duct System

In organs, the correct architecture of vascular and ductal structures is indispensable for proper physiological function, and the formation and maintenance of these structures is a highly regulated process. The analysis of these complex, 3-dimensional structures has greatly depended on either 2-dimensional examination in section or on dye injection studies. These techniques, however, are not able to provide a complete and quantifiable representation of the ductal or vascular structures they are intended to elucidate. Alternatively, the nature of 3-dimensional plastic resin casts generates a permanent snapshot of the system and is a novel and widely useful technique for visualizing and quantifying 3-dimensional structures and networks.
A crucial advantage of the resin casting system is the ability to determine the intact and connected, or communicating, structure of a blood vessel or duct. The structure of vascular and ductal networks are crucial for organ function, and this technique has the potential to aid study of vascular and ductal networks in several ways. Resin casting may be used to analyze normal morphology and functional architecture of a luminal structure, identify developmental morphogenetic changes, and uncover morphological differences in tissue architecture between normal and disease states. Previous work has utilized resin casting to study, for example, architectural and functional defects within the mouse intrahepatic bile duct system that were not reflected in 2-dimensional analysis of the structure1,2, alterations in brain vasculature of a Alzheimer's disease mouse model3, portal vein abnormalities in portal hypertensive and cirrhotic mice4, developmental steps in rat lymphatic maturation between immature and adult lungs5, immediate microvascular changes in the rat liver, pancreas, and kidney in response in to chemical injury6.
Here we present a method of generating a 3-dimensional resin cast of a mouse vascular or ductal network, focusing specifically on the portal vein and intrahepatic bile duct. These casts can be visualized by clearing or macerating the tissue and can then be analyzed. This technique can be applied to virtually any vascular or ductal system and would be directly applicable to any study inquiring into the development, function, maintenance, or injury of a 3-dimensional ductal or vascular structure.

A method of visualizing and quantifying the 3-dimensional structure of mouse hepatic portal vein or intrahepatic bile duct is described. This resin cast technique can also be applied to other ductal or vascular systems and allows for in situ visualization or quantification of a system's intact communicating architecture.

In  organs, the correct architecture of vascular and ductal structures is  indispensable for proper physiological function, and the formation and  ...

Laparoscopic Anatomical Hepatectomy Using Takasaki's Approach and Indocyanine Green Fluorescence Navigation

Laparoscopic anatomical liver resection is a standard treatment for liver cancer. Segmental resection of S4/5/7/8 is complex and lacks standardized procedures, leading to common complications. Innovative techniques are essential for enhancing safety and outcomes. A 45-year-old male with a history of hepatitis B, Child-Pugh Class A liver function, performance status (PS) score 0, and alpha-fetoprotein (AFP) level of 198.3 ng/mL was diagnosed with a 4 cm &#215; 5 cm &#215; 5 cm mass in S4/7/8, indicating primary hepatocellular carcinoma (HCC), closely associated with the middle and right hepatic veins (BCLC A). The 15-min retention rate of indocyanine green (ICG) was 7.8%. The standard liver volume (SLV) was 1073 mL, and the actual liver volume was 1345 mL. We performed laparoscopic resection of segments S4/5/8 and partial S7, resecting the middle hepatic vein (MHV) while preserving the right hepatic vein (RHV) because MHV was so closed with the tumor. The future liver remnant (FLR) was 590 mL, with an FLR/SLV ratio of 55%. The surgical procedure utilized Takasaki's approach to block the right anterior hepatic pedicle and fluorescence staining to identify the transection line. The operation lasted 205 min with an estimated blood loss of 150 mL. The patient experienced no postoperative complications and was discharged on the sixth day. Histopathology confirmed hepatocellular carcinoma with clear resection margins. Takasaki's approach, combined with ICG fluorescence navigation, significantly improves laparoscopic anatomical hepatectomy. This technique enhances visualization, reduces complications, and offers a new standard for complex liver resections.

Here, we present a protocol for laparoscopic anatomical hepatectomy using Takasaki's approach and indocyanine green fluorescence navigation in S4/5/7/8 resection.

Laparoscopic anatomical liver resection is a standard treatment for liver cancer. Segmental resection of S4/5/7/8 is complex and lacks standardized ...

Cancer Research

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In this study, a 32-year-old male patient with Bismuth Type IVa hilar cholangiocarcinoma underwent radical robotic resection of hepatic S4b, S5, and S1 (Taj Mahal hepatectomy) combined with regional lymphadenectomy, hilar bile duct reconstruction, and hepaticojejunostomy by the robotic surgical system. Postoperative pathological examination showed moderately-differentiated adenocarcinoma of the hilar bile duct. The surgical margins of the liver and bile ducts were negative. Recovery was smooth and the patient was discharged on the 17th postoperative day. The robotic surgical system and associated multiple instruments along with flexible and precise movements is suitable for the local hepatectomy around the porta hepatis, and delicate reconstruction of the hilar bile duct with a smaller diameter. This first clinical application study found that robotic Taj Mahal hepatectomy for hilar cholangiocarcinoma is safe and feasible and needs more experience for the evaluation of its long-term outcomes.

Robotic resection of hepatic S4b, S5, and S1 using the Taj Mahal procedure is feasible and safe for selected patients with hilar cholangiocarcinoma. The step-by-step details for this surgery are presented here.

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...

Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ultrasound, important vascular structures, and surgeon experience. With the development of anatomical hepatectomy, visual surgery technology has gradually been applied to this type of surgery, particularly indocyanine green (ICG)-guided anatomical hepatectomy. As ICG can be specifically ingested by hepatocytes and used for fluorescence tracing, negative staining techniques have been applied according to different tumor positions. Under ICG fluorescent guidance, the surface boundary and deep resection plane can be more accurately displayed during liver resection. Thus, the tumor-bearing liver segment can be anatomically removed, which helps to avoid damage to important vessels and reduce ischemia or congestion of the remaining liver tissue. Finally, the incidence of postoperative biliary fistula and liver dysfunction is reduced; therefore, a better prognosis is obtained after the resection of liver cancer. Centrally located liver cancer is usually defined as a tumor located at segments 4, 5, or 8 that requires resection of the middle section of the liver. These are among the most difficult hepatectomies to perform because of the large surgical wounds and multiple vessel transections. Based on the specific tumor location, we formulated the required resection ranges by designing personalized fluorescent staining strategies. By completing anatomical resection based on the portal territory, this work aims to achieve the best therapeutic effect.

The present protocol describes fluorescent negative staining in laparoscopic central hepatectomy. This technique can make hepatectomy more accurate and precise.

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ...

Complete Laparoscopic Radical Resection of Perihilar Cholangiocarcinoma Type IIIb

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With continuous advancements in laparoscopic techniques and instruments, laparoscopic radical surgery for pCCA is now considered technically safe and feasible. However, due to the high complexity of the surgery and the lack of evidence-based clinical support, laparoscopic radical surgery for type IIIb pCCA is performed only in a few large hepatobiliary centers. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA. Therefore, in this article, we provide a detailed description of the surgical steps and technical points of complete laparoscopic left hemihepatectomy combined with total caudate lobectomy, regional lymphadenectomy, and right hepatic duct-jejunal Roux-en-Y anastomosis in patients with type IIIb pCCA, using fluorescence navigation technology to enhance surgical precision and safety. By adhering to standardized surgical procedures and precise intraoperative techniques, we offer an effective means to improve patient outcomes.

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With ...

The Role of Indocyanine Green Fluorescence in Complex Laparoscopic Cholecystectomy Navigation

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for cholelithiasis and cholecystitis. In difficult cases with severe inflammation and adhesions, the risk of bile duct injury (BDI) is significantly higher. Precise identification of anatomical biliary structures is essential to prevent such injuries. Conventional intraoperative visualization techniques (IVT) have limited clinical application due to their complexity, increased trauma, and high error rates. Near-infrared fluorescence (NIRF) imaging, utilizing indocyanine green (ICG) as a fluorescent dye, has emerged as an innovative IVT technique. It is increasingly recognized as a feasible, safe, and effective approach for LC. However, the efficacy of NIRF in difficult LC procedures remains unclear, and the optimal timing and dosage of ICG administration are yet to be established. This article outlines the main steps for performing fluorescence-guided difficult LC in a patient with acute gangrenous cholecystitis and evaluates the imaging effects of NIRF in various scenarios. The patient was positioned supine, with four trocars placed. Upon switching to fluorescence mode, the fluorescently labeled bile ducts were readily identified. Following fluorescence guidance, Calot's triangle was carefully dissected. The cystic duct (CD) and cystic artery (CA) were individually identified and clipped before the gallbladder was extracted. Finally, the surgical field was inspected in fluorescence mode to detect bile leakage. With satisfactory ICG imaging and a smooth procedure, the patient's postoperative recovery was uneventful. NIRF is a safe and effective technology that shows great promise for future clinical applications.

This protocol outlines the steps for fluorescence-guided laparoscopic cholecystectomy and elucidates the role of fluorescence navigation in diverse surgical scenarios.

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for cholelithiasis and cholecystitis. In difficult cases with severe inflammation and ...

Trans-Arterial Indocyanine Green Staining for Precise Anatomical Hepatectomy of Liver Segments VII and VIII

Anatomical hepatectomy for resectable hepatocellular carcinoma (HCC) is performed with precision using the Glissonean system, ultrasound imaging, and indocyanine green (ICG) fluorescence staining to define liver segments, enhancing surgical radicality and preserving liver volume. However, laparoscopic clamping and ultrasound-guided ICG staining for deep-seated tumors in liver segments VII and VIII pose challenges due to the depth of the Glissonean ducts and other technical limitations. This study aimed to overcome these obstacles by exploring a protocol using trans-arterial ICG staining, a technique specifically tailored for complex anatomical hepatectomy of liver segments VII and VIII. In this method, an interventionalist accessed the right femoral artery and advanced to the celiac trunk for arteriography, followed by strategic placement of a microcatheter into the tumor's blood supply vessel to facilitate surgical resection. During the operation, ICG was injected through the microcatheter to fluorescently label the tumor's liver segment, enabling precise anatomical resection under fluorescence guidance. This trans-arterial ICG staining approach allows for the accurate identification of tumor subsegments, facilitates complete resection, and optimizes liver function preservation, ultimately improving oncological outcomes without increasing surgical complication rates.

Laparoscopic anatomical hepatectomy has gained global recognition in liver surgery. However, delineating tumor boundaries in liver segments VII and VIII presents distinct technical challenges. This protocol utilizes trans-arterial indocyanine green (ICG) staining to accurately identify liver subsegments, facilitating complete tumor resection while preserving functional liver volume.

Anatomical hepatectomy for resectable hepatocellular carcinoma (HCC) is performed with precision using the Glissonean system, ultrasound imaging, and ...

Laparoscopic Anatomical Resection of The Right Anterior Lobe Based on The Laennec Capsule Technique

This paper presents a laparoscopic anatomical resection technique for hepatocellular carcinoma (HCC) utilizing the Laennec capsule concept. The goal of this protocol is to improve surgical precision and safety during complex liver resections, particularly in tumors closely associated with vital vascular structures, by ensuring clear identification and dissection of critical anatomical landmarks. Surgical resection remains the primary curative treatment for hepatocellular carcinoma (HCC), but laparoscopic anatomical right anterior sectionectomy becomes particularly challenging when tumors are closely associated with major vascular structures, as this increases the risk of significant bleeding. Comprehensive preoperative treatment, including targeted therapy, immunotherapy, and hepatic arterial infusion chemotherapy (HAIC), can reduce tumor size and improve surgical outcomes, making previously borderline resectable tumors operable. In this case, a 75-year-old patient with a tumor in segment 8 (S8) of the liver, closely associated with major vascular structures, underwent two cycles of preoperative treatment. This reduced the tumor size from 6 cm by 5 cm to 4.5 cm by 3.1 cm. Laparoscopic anatomical right anterior sectionectomy was performed using the Laennec capsule, an anatomical structure that aids in vascular dissection. The procedure lasted 240 minutes with minimal blood loss (200 mL). The tumor was successfully resected with negative surgical margins, and the patient was discharged on the seventh postoperative day without complications. Postoperatively, the patient was monitored for signs of liver dysfunction and underwent routine imaging to assess for recurrence. Follow-up included liver function tests and regular CT scans, showing no recurrence after 6 months. This case demonstrates that the combination of the Laennec capsule technique and comprehensive preoperative treatment allows for precise, minimally invasive resections of HCC tumors closely associated with vascular structures, providing a safe and effective solution to challenging liver tumors with minimal intraoperative complications and promising postoperative outcomes.

This protocol describes a laparoscopic anatomical right anterior sectionectomy utilizing the Laennec capsule concept, combined with comprehensive preoperative therapy. The approach enables precise tumor resection in hepatocellular carcinoma (HCC) cases closely associated with major vascular structures, improving surgical safety, efficacy, and long-term patient outcomes.

This paper presents a laparoscopic anatomical resection technique for hepatocellular carcinoma (HCC) utilizing the Laennec capsule concept. The goal of ...

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Samenvatting

Meer video's verkennen