Standardization and Learning Curve of Robotic Left Hepatectomy Employing Glissonean Approach

Robotic liver resection (RLR) is widely performed as an alternative to laparoscopic liver resection. Many different surgical robot systems (SRSs) have been developed; however, there are relatively few standardized RLR procedures that can be applied to the use of different SRSs. We present a standardized robotic left hepatectomy (RLH) procedure for different SRSs and the learning curve derived via cumulative sum analysis.

We performed 14 cases of RLH using our standardized procedure. We mobilized the left lobe, and the round ligament was drawn to the caudal side. The omental bursa is opened, and the Arantius duct is carefully transected. The left Glissonean pedicle was encircled and transected using a linear stapler after confirming the demarcation line. Parenchymal transection is gently performed using the clamp-crush technique (intermittent Pringle's maneuver). The root of the left hepatic vein was visualized at the end of the parenchymal transection, and this vein was transected using a linear stapler.

In our series, there were no intraoperative transfusions or conversions. One case of bile leakage required endoscopic treatment, and the patient survived. The learning curve plateaued at seven cases of RLH. Our standardized RLH procedure, which includes the Glissonean approach and the clamp-crush method, can be applied to all SRSs without any specific energy devices.