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Page 2 of 9 Nota et al. Mini-invasive Surg 2020;4:74 I http://dx.doi.org/10.20517/2574-1225.2020.57

Keywords: Robotic liver resection, minimally-invasive hepatectomy, robot-assisted surgery, robotic surgery, hepatic
resection

INTRODUCTION
The benefits to the patient of a minimally invasive approach to liver resection include fewer complications,
[1]
less blood loss, and an enhanced recovery after surgery . Conventional laparoscopy, however, has technical
limitations. Laparoscopic instruments have a straight work-axis and, therefore, have limited freedom of
movement. To overcome these impairments the surgical robot was introduced, which provides articulating
[2,3]
instruments, a 3-dimensional view, and scaled movements . Several studies have shown the safety and
[4]
feasibility of robotic liver resection .
During liver resection, transection of the hepatic parenchyma forms an essential part of the procedure.
Inadequate sealing of vascular and biliary structures can result in bile leakage or bleeding, potentially
causing postoperative complications and mortality. Several techniques and devices have been developed
for parenchymal transection, such as the clamp crushing technique, cavitron ultrasonic surgical aspirator
(CUSA) (Integra LifeSciences, Tullamore, Ireland), ultrasonic devices, staplers and mono- and bipolar
[5,6]
devices . Most of these techniques were developed for, and are predominantly used in, open surgery. In
laparoscopic liver surgery, the transection is mostly performed using CUSA, sealing devices and staplers.
For robotic surgery, it has not yet been determined which device is best suited for parenchymal transection.
Currently, the robotic Harmonic Scalpel (Intuitive Surgical, Sunnyvale, California, USA) or robotic bipolar
cautery (Maryland Bipolar Forceps, Intuitive Surgical, Sunnyvale, California, USA) are the most frequently
reported devices used for parenchymal transection during robotic liver resection . However, the robotic
[7]
Harmonic Scalpel lacks the ability to articulate and the Maryland Bipolar Forceps seems not optimally
suited for larger transection planes.

TM
The EndoWrist® One Vessel Sealer (on the Xi/X robotic systems: EndoWrist® One Vessel Sealer Extend)
TM
(Intuitive Surgical Inc., Sunnyvale, CA, USA) is a fully wristed robotic energy device (60° of articulation
in all directions for the Extend) that is approved to seal and cut vessels up to 7 mm in diameter. The aim
of this study is to report the technical details and clinical outcomes of a series of consecutive robotic liver
resections during which the Vessel Sealer was used for parenchymal transection.

METHODS
Study design
This is a post hoc analysis of a prospective database. In addition, recordings of the surgical procedures
were reviewed retrospectively for determination of parenchymal transection duration. All consecutive
patients who underwent robotic liver resection in the Regional Academic Cancer Centre Utrecht
(RAKU) at both University Medical Centre Utrecht and St. Antonius Hospital Nieuwegein, between 1st
August 2015 and 11th January 2019, were included. Patients were selected for robotic liver resection in a
multidisciplinary board meeting. As this case series also reflects a learning curve of robotic hepatectomy
starting with easy minor resections and progressing to difficultly-located minor resections, and eventually
hemihepatectomy, no uniform inclusion criteria are applicable. In general, exclusion criteria for the robotic
approach in this series were extended liver resection (> 4 segments), tumour adjacent to the inferior
vena cava or hepatic vein insertions, and perihilar cholangiocarcinoma. In the first cases, cirrhosis was a
relative contraindication (unless minor/wedge resection) but, with growing experience, this was no longer
considered a contraindication.