Robotic Right Anterior Sectionectomy with Extraglissonean Approach for HCC

Background: Robotic surgery is gaining momentum in liver resection due to its three-dimensional (3D) magnified view and articulated instrumentation.1 However, some criticism has been raised regarding the anatomical "quality" of parenchymal transection planes in the absence of a specific instrument for parenchymal transection usable by the console's surgeon. Major hepatectomy is traditionally required in case of large hepatocellular carcinoma (HCC) (> 5 cm), however, recent data suggest that minor resections may yield similar outcomes when technically feasible and oncologically adequate.2 This video demonstrates a fully robotic anatomical right anterior sectionectomy (RAS) with extraglissonian approach for HCC. Patient and methods: A 6-cm Sg8 nodule with washout, suggestive of HCC, resting on the middle hepatic vein (MHV) and right hepatic vein (RHV), with involvement of the right anterior Glissonian pedicle (RAGP), was diagnosed in a very motivated 85-year-old male patient with excellent physical shape (PS 0) and hepatitis C virus (HCV)-related chronic liver disease. Four robotic trocars and one laparoscopic port for assistance were placed, and the da Vinci Xi system was docked. RAGP was isolated by extraglissonean and transected with a stapler. After marking with US and ICG, parenchymal transection was performed with complete exposure of RHV and MHV. Operative time was 480 min, blood loss was 300 ml, clamping time 3 × 15 min. No complications occurred, and the patient was discharged on postoperative day 6. Pathology confirmed HCC pT1b R0 resection G1. Conclusions: This video confirms the feasibility and safety of fully robotic anatomical right anterior sectionectomy with extraglissonean approach also in elderly patients.3-4.