Robotic Partial Central Hepatectomy for Juxtahilar Tumor: Technique of Middle Hepatic Vein Tangential Reconstruction

Minimally invasive techniques for resection of centrally located tumors near the region of hepatic duct bifurcation poses technical concerns to many hepatobiliary surgeons. Excessive bleeding, inadvertent injury to the hilar plate with subsequent bile leak and abdominal sepsis, and involvement of the middle hepatic vein (MHV) often deter surgeons from using a minimally invasive technique in this circumstance. An emerging robotic method with advantages over conventional laparoscopy offers greater technical feasibility for peri-/juxtahilar dissections and MHV ligation/reconstruction. Although robotic portal vein resection and reconstruction has been established and widely reported in the literature, especially in pancreaticoduodenectomy or Klatskin tumor resection,^1-5 technical descriptions of hepatic vein reconstruction remain limited. Herein, we describe our technique for robotic partial central hepatectomy for juxtahilar tumor, highlighting steps of MHV tangential reconstruction to avoid congestion of the associated hepatic parenchyma drained by the MHV trunk.

A 57-year-old woman presented with a single 5 cm segment V hypermetabolic mass, concerning for metastatic breast cancer without evidence of extrahepatic disease. She had a multifocal invasive adenocarcinoma requiring partial mastectomy and antiestrogen treatment 11 years before her current presentation. Magnetic resonance imaging showed a 5 cm liver mass almost in contact with the hepatic duct bifurcation dorsally and laterally displacing the middle portion of the MHV. Robotic partial central hepatectomy under intermittent Pringle maneuver was undertaken using a meticulous crush-clamp technique to avoid injury to the hilar plate, and tangential reconstruction of the MHV using a curved vascular bulldog clamp was completed without intraoperative complications.

The robotic operation was completely uneventful, with minimal blood loss, and the patient had an uneventful recovery followed by hospital discharge on postoperative day 3. A final pathology report was consistent with metastatic breast cancer with negative resection margins. At 16 months after the robotic liver resection, the patient remains without evidence of disease recurrence.

Although robotic approaches to resection and reconstructive techniques for the portal vein and inferior vena cava have been discussed, very little is known about resection and reconstructive techniques for the major hepatic vein during robotic hepatic resection. Preservation of the major hepatic vein, such as MHV, is important to avoid parenchymal venous congestion of the corresponding liver sector, which in theory can compromise overall liver function in patients with marginal future liver remnant volume or hepatic functional reserve secondary to underlying liver disease. In the case presented here, the right anterior sector (segment 5/8) is dominant, with 37% portion volume, so adequate parenchymal venous drainage via MHV was clinically important and necessary. Adequate inflow, outflow, and biliary drainage are three widely known key factors that determine postoperative hepatic recovery and parenchymal regeneration. Another observation on the preoperative imaging was that a segment IV bile duct was focally dilated because of mechanical local tumor compression/involvement onto the segmental bile duct, which was directly located dorsal to this mass. Beyond this localized radiological finding, no clinical symptoms were observed. The tumor did not invade the roof of the hilar plate, so R-0 resection margins were easily obtained. A hepatic vein reconstruction technique such as shown in this video can be similarly applied for other major hepatic veins such as the right and left hepatic veins. We anticipate that this robotic technique for reconstructing major hepatic veins will become significantly more relevant in cases of upper segmental tumor resection, as reported by Procopio et al.⁶ As such, tumor resection using a robotic approach can be maximally optimized.

Application of a robotic technique is safe and feasible for juxtahilar tumors requiring precise dissection and reconstruction of the major hepatic vein trunk. We believe that the robotic surgical system allows for challenging hepatic tumor resections in difficult locations and hepatic vascular preservation using reconstructive techniques.