Background: 42 y.o. female. PMH/PSH: neoadjuvant CHT for rectal adenocarcinoma with metastasis(biopsied) and robotic abdominoperineal rectal resection. Re-evaluation workup: good CHT response, and stable metastasis exclusively localized in the right lobe of the liver (S6, S7-8).
Procedure Performed: Robotic Right Hepatectomy. Patient supine in lithotomy. Pneumoperitoneum: Veress technique. Exploratory laparoscopy: normal findings. Trocars(see Video). Division(Harmonic) of the round/falciform ligaments. Intraoperative US: S6 lesion, and a deeper one in S7-S8.
STEP 1-Hilum dissection. Cholecystectomy keeping the cystic duct stump long(for retraction). Hilum dissection is started. The right hepatic artery (RHA) is skeletonized, clamped(bulldog), and divided after Doppler confirmation of the blood supply distribution. The right hepatic duct is divided intra-capsularly because of the unclear biliary bifurcation, even after ICG. Some branches going to S1. Dissection(hook) of the right branch of the portal vein, which is then divided(vascular stapler).
STEP 2-Hepatocaval dissection.R4 retracts the right lobe. Division of the triangular/coronary ligaments up to the vena cava. Two short hepatic veins are divided(Prolene 4-0). The main right hepatic vein is reached, but not divided at this stage.
STEP 3-Parenchymal Transection. Stay sutures(Prolene 2-0) on S4. Layer-by-layer liver dissection (Harmonic shear). Hemostasis by Prolene 4-0 stitches. Once into the parenchymal core: liver division using stapler(vascular load), including the right biliary duct and the right hepatic vein, up to the achievement of complete right lobectomy. Hemostasis. Fibrin glue. Falciform ligament reconstruction. Specimen retrieved (Pfannenstiel incision). Intra-abdominal hemostasis check.
Results: OT: 340 min. EBL: 300 ml. Uneventful postoperative course. POD 4 discharge.