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underwent extended hepatectomies (> 4 segments), or patients who had a past medical history of extensive
abdominal surgery, were in general not deemed fit for a robotic approach. Although our resections might
not fully represent the entire spectrum of liver resections, there were ten major resections performed (14%)
and indications varied widely, including patients with cirrhosis (11%). Moreover, 45 patients (64%) were
selected who underwent previous abdominal surgery, including previous liver surgery in 6 patients. Second,
some surgeons consider the tip of the Vessel Sealer to be too bulky and prefer a more refined instrument
for transection of the parenchyma and dissecting out hepatic structures. The updated version of the Vessel
Sealer, the Vessel Sealer Extend, however, has a slimmer jaw profile and therefore allows for more delicate
dissection. Third, the retrospective nature of the study holds an inherent risk of bias. The comparison we
conducted with conventional laparoscopy is obviously weaker than a head-to-head comparison. However,
since the outcomes of all laparoscopic liver resections performed in the Netherlands are provided, these
results reflect the true outcomes after conventional laparoscopic liver resection.

Based on the results of this series, consisting of 60 minor liver resections and 10 hemihepatectomies, we
conclude that the use of the Vessel Sealer during the parenchymal transection in liver resection is feasible
and safe.

DECLARATIONS
Acknowledgments
The authors would like to thank Prof. Yuman Fong (Department of Surgery, City of Hope Medical Center,
Los Angeles) for his advice and support during the set-up of the robotic liver surgery program at University
Medical Center Utrecht. The authors also like to thank Prof. Dr Marc G. H. Besselink and Dr Burak Gorgec
(both of Department of Surgery, Amsterdam UMC, location: AMC) for providing additional data from
their study.

Authors’ contributions
Made substantial contributions to the design of the work, the data acquisition and analysis, and drafting of
the manuscript: Nota CL, Molenaar IQ, te Riele WW, van Santvoort HC, Borel Rinkes IHM, Hagendoorn J

Availability of data and materials
Data are extracted from a prospectively maintained, secured institutional database. Due to the institution’s
privacy regulation, raw data won’t be shared online.

Financial support and sponsorship
None.

Conflicts of interest
Prof. Dr. I. Quintus Molenaar and Dr. Jeroen Hagendoorn are proctor for Intuitive Surgical (Intuitive
Surgical Inc., Sunnyvale, CA, USA). The content of this study is solely the responsibility of the authors and
does not necessarily represent the official views of Intuitive Surgical. All other authors have declared no
conflict of interest.

Ethical approval and consent to participate
Data were extracted from an anonymized database. Hence the study was waived from informed consent.

Consent for publication
Not applicable.