Robotic right hepatectomy via an anterior approach: technical considerations for managing large hepatocellular...

Large hepatocellular carcinomas (HCCs) represent significant surgical challenges, for which the anterior approach technique has been advocated to reduce the risk of tumor cell dissemination by avoiding direct tumor manipulation during mobilization, ultimately leading to improved operative and survival outcomes compared to the conventional approach. However, the technical complexity of this procedure limits its adoption, even when performed via the traditional open approach. Accordingly, despite the widespread adoption and safe performance of minimally invasive liver resections in many institutions, their application to large hepatic lesions remains limited due to technical challenges, particularly in cases of huge lesions (10 cm). Herein, we illustrate a stepwise robotic right hepatectomy via an anterior approach in a 79-year-old man with a large (13 cm) hepatocellular carcinoma, performed using the Da Vinci Xi system. After intrafascial extrahepatic control of the right hepatic vessels, a fully robotic right hepatectomy was progressively carried out via an anterior approach. For the parenchymal transection, a dual bipolar technique was mainly adopted in combination with a Vessel Sealer device placed in the 4th robotic arm. The procedure was completed without the need for pedicular clamping. Operative console time was 227 minutes, and estimated blood loss was 50 mL. The postoperative course was uneventful, and the patient was discharged on postoperative day seven. This technical note illustrates a stepwise technique for performing a robotic right hepatectomy for huge hepatic lesions using an anterior approach. It aims to serve as a practical guide for hepatobiliary surgeons managing voluminous lesions through a minimally invasive approach.