Robotic parenchyma-sparing resection with a multiplanar-driven approach: the mini-rollercoaster hepatectomy

For tumors close to the hepatic veins (HV), anatomical plane dissection is usually preferred in minimally invasive surgery to ensure oncological radicality and a safer and less technically demanding procedure. Drawing from open surgery experience with intraoperative ultrasound (IOUS) guidance and preoperative 3D casts, the concept of transversal hepatectomy performed along a multiplanar plane crossing the HV, termed "rollercoaster hepatectomy", has been proposed. Its feasibility as a robotic parenchyma-sparing strategy remains largely unexplored. We report a case of liver metastases treated with a robotic multiplanar-guided resection exposing the left hepatic vein (LHV). Given the favorable response to chemotherapy, the technical feasibility of the procedure, and the possibility of achieving oncological radicality, a parenchyma-sparing transversal approach was considered appropriate. The surgical procedure was built upon: (1) preoperative 3D rendering for precise tumor-vascular assessment and surgical planning; (2) IOUS for guidance during parenchymal transection; (3) adequate liver mobilization with caval confluence exposure and HV taping to manage potential backflow bleeding; and (4) parenchymal transection via the clamp-crushing technique with the SynchroSeal device to skeletonize Glissonean pedicles and LHV. A robotic R0 limited resection of segment 2 crossing the LHV ("mini-rollercoaster resection") was performed instead of left sectionectomy. The operation lasted 235 min, including 30 min of intermittent Pringle maneuver, with minimal blood loss. Postoperative recovery was uneventful, with a 6-day hospital stay. This preliminary experience demonstrates the potential application of transversal hepatectomy via multiplanar dissection in the robotic setting. Further studies are needed to assess its feasibility, reproducibility, and standardization in more complex scenarios.