Robotic Right Posterior Sectionectomy by Intrafascial Approach for Pancreas Neuroendocrine Liver Metastasis

Liver resection is indicated for resectable liver metastases of neuroendocrine tumors.¹ Minimally invasive liver resection offers decreased blood loss, reduces pain, reduces postoperative complications, and reduces time to functional recovery.² However, access to posterior section remains difficult with conventional laparoscopic tools. The robotic approach could overcome these limitations.

A 46-year-old woman had a pancreatic neuroendocrine tumor with synchronous liver metastases (18 mm in segment 6, 29 mm in segment 7, and 31 mm in segment 8). Due to stable disease after 2 years of somatostatin analog treatment, surgical management was decided. The first step was robotic distal pancreatectomy. Two months later, we performed a posterior sectionectomy associated with a wedge resection in segment 8.

Da Vinci X robot was used. Surgery was conducted with a second surgeon located between the patient's legs using suction/irrigation device and ultrasonic dissector through laparoscopic ports. The posterior sectorial branches of the hepatic artery and portal vein were controlled via an intra-fascial approach. Robotic parenchymal dissection was performed by a four-hands method,³ with laparoscopic ultrasonic dissector and robotic irrigated bipolar guided by indocyanine green. Transection was led on the right side of right hepatic vein without clamping. Operative duration was 330 min, and estimated blood loss was 50 ml. Postoperative course was complicated by grade B biliary fistula. The patient was discharged on postoperative day 10.

This case illustrates the feasibility and safety of a robotic approach for right posterior liver sectionectomy, which can improve the dexterity of the surgeon and thus the possibility of difficult minimally invasive liver resection.