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Page 4 of 6 Ishizawa et al. Mini-invasive Surg 2021;5:52 https://dx.doi.org/10.20517/2574-1225.2021.81

Hepatic segmentation by fluorescence imaging for anatomic resection
Because the latest robotic surgical systems are equipped with near-infrared imaging technology (da Vinci
Firefly; Intuitive Surgical, Sunnyvale, CA, USA), intraoperative fluorescence imaging using indocyanine
green (ICG) can be easily applied to RAH as well as LH and open hepatectomy for real-time visualization of
[17]
the biliary anatomy (fluorescence cholangiography), liver cancers, and boundaries of hepatic segments .
Among these procedures, hepatic segmentation can be achieved by direct injection of ICG into the target
portal branch (positive staining technique) [18,19] or by systemic injection of ICG following closure of the
portal pedicle feeding tumor-bearing hepatic segments (negative staining technique) [18,20] . If a robotic
surgical system could be used to perform a positive staining technique, it would facilitate easier puncture of
[21]
the target portal branch under ultrasound guidance compared with laparoscopic needle manipulation .
The use of robotic surgical devices also enables multidirectional dissection of the hepatic hilum to reach the
[22]
corresponding Glissonian sheaths to be divided , which may extend the indications for the negative
staining technique to anatomic resection of deeply located hepatic segments. Although near-infrared
imaging has been installed in the latest model of laparoscopic imaging systems as well as robotic surgical
systems, use of this technology with multi-articulated forceps and three-dimensional color imaging may
further extend applications of fluorescence imaging during hepatobiliary surgery.

Integrated surgical navigation, autonomous actions, and surgical decision-making by artificial
intelligence
In addition to intraoperative information obtained by techniques such as fluorescence imaging and
ultrasonography, preoperative simulation can be placed in the surgeon’s console of the robotic surgical
system and displayed in real time with three-dimensional images of operative fields. In this respect, RAH
has a potential advantage over LH in terms of the ability of surgeons to understand special relationships
between anatomical structures and tumors by integrating preoperative and intraoperative imaging
information. Applications of augmented reality and artificial intelligence may further promote the
[23]
[24]
development of surgical navigation systems. In addition, application of artificial intelligence in robotic
surgery may enable autonomous control of surgical installments like a laparoscope and staplers and provide
[25]
precision information for accurate surgical decision-making .
POSSIBLE DISADVANTAGES OF APPLYING ROBOT-ASSISTED SURGERY TO
HEPATECTOMY
As mentioned previously, the major disadvantage of RAH over LH is the higher cost associated with the
initial installation and use of each instalment. Especially in Japan, the amount of future insurance claim for
RAH may be the same as that for LH as in the case of pancreatectomy, which can press management of the
medical institutions. Limited lineup of aspiration and dissection devices (no angular ultrasonic dissectors)
designed for hepatic parenchymal transection is another drawback of RAH, leading to longer operation
time than LH as demonstrated in previous studies . We expect that the next-generation robotic surgical
[7-9]
systems are devised with the opinions from liver surgeons to adjust to the specific conditions of
hepatectomy.

CONCLUSIONS
With the accumulation of evidence indicating the specific advantages of RAH over LH, robotic surgical
systems will become more commonly used for hepatobiliary surgery in Japan as well as in other countries.
After reimbursement by the health insurance system, we aim to apply RAH with prioritization of surgical
safety using a nationwide reporting system and board certification systems for the performance of LH and
robot-assisted pancreatic resections.