Precision Robotic Glissonean Approach for High-Branching G8 Pedicles in Hepatocellular Carcinoma

Anatomical liver resection benefits from controlling Glissonean pedicles before parenchymal transection to ensure accurate anatomical boundaries. In segment 8, high-branching Glissonean anatomy can hinder identification of the targeted pedicle, increasing the risk of misidentification. A hilum-first, stepwise intrahepatic approach facilitates safe and precise isolation of each ramification. We present a case of robotic S8 segmentectomy for hepatocellular carcinoma (HCC), using a strategy adapted to this anatomical variation.

An 83-year-old male with HCC in S8 underwent robotic segmentectomy. Preoperative imaging revealed high-branching of G5 from G8 branches. The anterior Glissonean pedicle was first encircled. (1) G5d + G8d and (2) G5v were isolated, enabling identification of G8v and G8d by subtraction. These branches were selectively clamped, and ICG-negative staining guided precise anatomical resection. The robotic system's enhanced dexterity and magnified 3D vision enabled atraumatic handling of these fine branches.

This approach allowed more distal pedicle division than initially planned, preserving 104 mL (10%) of functional liver. Blood loss was 10 mL/kg, and no complications occurred. The patient was discharged on postoperative day 6. Pathology confirmed moderately differentiated HCC (T2N0M0, UICC 8th) with negative margins and no microvascular invasion.

Robotic liver resection enables precise and atraumatic intrahepatic Glissonean dissection, particularly in cases with high-branching Glissonean anatomy. A hilum-first, stepwise approach-combined with real-time ICG fluorescence imaging-offers a reliable method for safely isolating targeted pedicles, thereby enhancing oncological precision and preserving functional liver volume in challenging segment 8 resections.