Robotic bona fide right hepatectomy with ICG-guided detachment technique

Anatomic liver resection (ALR) requires precise transection along the true intersegmental/sectional plane while preserving vascular integrity of the remnant liver. Conventional approaches often rely on ischemic demarcation or venous landmarks, which may not perfectly match anatomical boundaries. Robotic platforms and indocyanine green (ICG) fluorescence have enabled refined visualization and dexterity, supporting the concept of bona fide ALR-defined as anatomical resection that exactly follows the Glissonean territory while preserving remnant inflow and outflow integrity. The "detachment technique" denotes a robotic ICG-guided approach that achieves natural parenchymal separation along the demarcated plane through controlled traction-countertraction dynamics, ensuring anatomical precision without unnecessary vessel sacrifice. Conceptually, this principle applies to any segmental or subsegmental unit of the liver representing the smallest anatomical territory supplied by a Glissonean pedicle.

We report robotic right hepatectomy in a woman in her 50s with abdominal fullness due to a giant hepatic hemangioma. Using the Da Vinci Xi system, cystic plate cholecystectomy was performed, and the right hepatic artery was ligated to reduce tumor tension. After encirclement of the hepatoduodenal ligament, the right Glissonean pedicle was isolated using an extrahepatic approach. Intravenous injection of 0.25 mg ICG enabled negative staining, which delineated the transection plane. Parenchymal transection was carried out with a Maryland bipolar dissector under robotic countertraction, facilitating natural detachment along the Main Portal Fissure. Firefly mode provided real-time visualization, and the anterior and posterior Glissonean pedicles and the right hepatic vein were divided with staplers.

The procedure was completed in 407 minutes with an estimated blood loss of 116 mL. The postoperative course was uneventful, and the patient was discharged on postoperative day 7.

Robotic right hepatectomy with a Glissonean approach and ICG-guided negative staining illustrates the feasibility of bona fide anatomic liver resection (ALR). While demonstrated in a single case of hemangioma, this technique requires expertise in the extrahepatic Glissonean approach and should be validated in multicentric cohorts to assess its generalizability and long-term outcomes.