Robotic hepatectomy: the Korean experience and perspective

Abstract

Since the robotic surgical system was first introduced in 2005, the number of robotic surgery has been gradually increasing in Korea. The proportion of general robotic surgery is relatively higher compared to the western countries, but robotic liver resection is one of the most complex procedures among robotic general surgery. In this article, we introduce the development of robotic liver resection in Korea and describe our standardized techniques. The current data on robotic liver resection in our institute and other centers in Korea are also presented.

Keywords: Robotic liver resection; anatomic liver resection; minimally invasive liver resection.

Figure 1

The annual number of robotic surgery in Korea from 2005 to 2015.

Figure 2

The drawing of the rubber band suspension method. The rubber bands are fixed at the right and left resection margins, respectively, using stay stitches (A). The other end of the rubber band is pulled out using Endo closure and fixed on the abdominal wall using a Mosquito clamp with appropriate tension (B and D). Stable traction is made and the liver is ready to be transected (C). To prevent CO₂ leakage during operation, a small hole through which the rubber band is pulled out should be filled with gauze (D). Spatial configuration of robotic instruments and the rubber band suspension during parenchymal transection is shown in (E).

Figure 3

The direction of the tip of Harmonic scalpel is identical to the parenchymal transection plane for hemi-hepatectomy when it is mounted on the second arm (the left hand).

Figure 4

During anterior sectionectomy, the right anterior portal pedicle (RAP) was partially exposed (A) and bulldog clamp was applied (B). The ischemic demarcation line was clearly identified on the liver surface (C). The right anterior portal pedicle was completely isolated during parenchymal transection (D) and divided using a linear stapler.

Figure 5

Operative time and estimated blood loss in 19 consecutive left hepatectomy excluding combined procedures such as radiofrequency ablation, choledocholithotomy and lymph node dissection around the hepatic hilum. After the 10^th case, operative time became stabilized around 5 hours with minimal blood loss.

Figure 6

Indocyanine green (ICG) image-guided parenchymal transection. ICG was directly injected into the left portal vein (A). The border between segment 4a and segment 8 was more clearly identified under ICG image (B) than gross vision (C). During parenchymal transection, ICG image enabled us to properly follow the proper transection plane (D and E). The left liver parenchyma was completely removed (F).