Robotic Extended Hepatectomy

With increased adoption of robotic hepatectomy, indications have expanded to include major resections such as extended hepatectomy. When performed by experienced surgeons, extended hepatectomies can be completed robotically with similar outcomes to both open and laparoscopic approaches. In fact, the robotic platform may enable more difficult or extensive resections previously performed in an open approach to be completed in a minimally invasive manner. Meticulous preoperative planning is essential to determine the precise extent of resection, characterize any variant anatomy, and evaluate the future liver remnant to avoid postoperative hepatic failure. Key operative principles include strategic robotic port placement in anticipation of resection extent and parenchymal transection plane, assistant port placement for ancillary equipment and instrumentation, intraoperative ultrasound before and during parenchymal transection, and indocyanine green for intraoperative evaluation of perfusion. Conversion to open may be non-emergent or emergent. Surgeons undertaking extended robotic hepatectomy should be familiar with both open resection and biliary and vascular reconstruction techniques.