Right Hemihepatectomy, Robotically Assisted

• Positioning: Supine position with legs spread on a vacuum cushion. The cushion ensures stability, reducing the need for additional supports
• After trocar placement, the table is tilted to a 15° – 30° Anti-Trendelenburg position to optimize access
• Robot Docking:
  • The Xi system offers flexibility in the docking position, typically from the left
  • For X or Si systems, the cart is docked cranially from the right
• Team Positioning:
  • Surgeon: At the console, ideally with a view of the patient and assistant
  • Assistant: Positioned between the legs, sitting or standing
  • Scrub Nurse: On the right side of the patient
  • Anesthesiologist: At the patient’s head, on the right side

Pneumoperitoneum Creation:

• Use a Veress needle at the Palmer point in the left upper abdomen.
• Establish an insufflation pressure of 12–15 mmHg
• Alternatively, employ Optiview technique

Trocar Placement:

• Total Ports:
  • Four 8 mm robotic ports in a linear arrangement, 15–20 cm from the target anatomy (infraumbilical)
• Two 12 mm laparoscopic ports:
  • Assistant trocar (caudal between robotic ports 2 and 3)
  • Pringle maneuver trocar (caudal between robotic ports 1 and 2)
  • Spacing: Approximately 8 cm between each port
  • Position robotic trocars at the level of the muscular abdominal wall (aligning the broad black ring, the “Remote Center”)

Initial Instrument Configuration:

• Robotic ports (from right to left):
  • Port 1: Monopolar curved scissors
  • Port 2: Camera
  • Port 3: Bipolar forceps
  • Port 4: Prograsp forceps

  Docking the Robot:

• Dock the camera arm first (port 2)
• Execute Targeting (Xi system) to align robot arms with the surgical target
• Dock the remaining arms, ensuring 1 fist-width spacing between them
• Insert instruments under direct visualization via the assistant trocar

Key Precautions and Tips

Trocar Stability:

• Ensure the “Remote Center” aligns with the muscular abdominal wall to minimize shear forces during instrument movement

Instrument Placement:

• Use the assistant trocar and camera to inspect trocar alignment and verify instrument positioning before proceeding

Preventing Patient Movement:

• Double-check the vacuum cushion for leaks before sterile draping
• Secure arms during docking to avoid injury if the patient shifts

Control Checks:

• Before docking:
  • Mark trocar points and ensure proper spacing
  • Introduce the camera manually for inspection
• After docking:
  • Verify arm alignment and positioning of instruments

• Perform a small incision in the left upper abdomen for Veress needle placement
• Establish pneumoperitoneum at 15 mmHg
• Mark the trocar line and insert the first robotic trocar
• Insert the camera manually to confirm placement
• Sequentially place:
  • Three additional robotic trocars (8 mm)
  • Two laparoscopic trocars (12 mm) in the caudal positions
• Transition to Anti-Trendelenburg position (15°)
• Dock the camera arm and insert the camera
• Perform Targeting with the Xi system
• Dock the remaining three arms
• Insert instruments and park them at the target anatomy:
  • Port 1: Monopolar curved scissors
  • Port 2: Camera
  • Port 3: Bipolar forceps
  • Port 4: Prograsp forceps
• Inspect remote centers via the assistant trocar to ensure proper alignment

This systematic approach optimizes patient safety, instrument positioning, and robot utilization, ensuring precision in robotic-assisted right hemihepatectomy.

Adhesiolysis:

• Release adhesions between the omentum majus, gallbladder, and inferior liver surface
• Grasp the gallbladder fundus with the Prograsp Forceps and retract cranially
• Expose the entire gallbladder to the infundibulum

 Intraoperative Ultrasound:

• Insert the ultrasound probe through the assistant trocar
• Guide the probe with fenestrated bipolar forceps for precise movement
• Objective:
  • Visualize lesions and their relationship to vessels and bile ducts
  • Confirm the tumor-free status of the left liver lobe
  • Identify critical landmarks, including the middle hepatic vein and segmental branches to Segments V/VI and VIII

Marking the Resection Line:

• Using monopolar scissors, mark the resection line on the ventral liver capsule under ultrasound guidance

Create a window between the ligamentum teres and the abdominal wall

Gradually divide both ligaments with meticulous coagulation, progressing from caudal to cranial up to the diaphragm and coronary ligament

• Tip: Use the detached ligamentum teres as a traction point for atraumatic manipulation of the liver during the procedure