Pencil cleaning technique for robotic liver parenchymal transection: a step further to systematization beyond the microfracture-coagulation method

Abstract

Robotic liver resections based on Laennec's capsule pedicular driven dissection is a challenging surgical procedure, because of the intrinsic relationship between the liver parenchyma and the main intrahepatic vessels. The absence of anatomical landmarks and the frailty of the fine vascular structures requires broad experience, anatomical knowledge and refined technical skills to successfully perform such a procedure. As robotic platforms do no offer the standard laparoscopic advanced tools for liver resection, real robotic approach has been proposed as a default technique for the liver parenchymal transection, precise robotic anatomical and parenchymal-sparing liver resection, and pedicle driven dissection, like the microfracture-coagulation method. A more specific refinement of the real robotic approach, similar to the pencil cleaning process, useful in very careful deep dissections, is defined towards the standardization of the real robotic approach in advanced liver surgery. The rationale of the method, its indications and tips and tricks are described in detail.

Keywords: Liver parenchymal transection; Liver surgery; Microfracture-coagulation; Pedicle driven approach; Pencil cleaning; Real robotic approach; Robotic liver surgery.

Fig.1

Pencil cleaning systematic dissection technique. 1: closed scissor in contact with the main middle vein, 2: closed scissor brushes the vessel wall like a pencil, uncovering the main middle vein

Fig. 2

Minor anatomic (segmentectomy) and parenchyma-sparing (wedge) cumulative robotic liver resections histogram