How I do it: robotic living donor right hepatectomy with a focus on parenchymal transection

Abstract

Background: Living donor liver transplantation provides a solution to the shortage of deceased donor organs. As minimally invasive donor hepatectomy has gained popularity, robotic techniques offer clear advantages, such as enhanced visualization, precision, and ergonomics.

Methods: Our institution began robotic liver surgery in 2008 and introduced robotic donor hepatectomies in 2016. With growing experience, we established a standardized approach for robotic donor right hepatectomy (RDRH), focusing on parenchymal transection and bile duct division.

Results: We suggest a zone-based approach along the middle hepatic vein by dividing the transection plane into four zones based on venous territories. This systematization improves the orientation, minimizes bleeding, and facilitates precise dissection. Key anatomical landmarks, such as segmental veins (V5 and V8), the Laennec's capsule, and intersegmental veins, guide the dissection. Supplementary Videos and Figures for each step demonstrate specific techniques, including the inter-Laennec approach and modified hanging maneuver. Bile duct division is guided by indocyanine green fluorescence and performed using either a "clip and cut" or "cut and suture" method, chosen based on individual duct anatomy.

Conclusions: Robotic articulation facilitates secure closure even in anatomically challenging cases. These standardized techniques enable reproducible outcomes and support their safe adoption by centers new to RDRH.

Keywords: Liver donor; Parenchymal transection; Robotic surgery.