Abstract
Introduction:
The safety and efficiency of laparoscopic approach for resection of colorectal liver metastasis have been confirmed in two recent international consensus conferences and one randomized controlled trial, the OSLO-COMET trial. 1 –3 However, laparoscopy may be limited because of technical difficulties especially for managing intraoperative bleeding. The surgical robot has the potential to overcome these limits. 4 This video shows robotic management of a retrohepatic vena cava injury during a segment 7 wedge resection.
Materials and Methods:
A 71-year-old patient underwent a primary left colon cancer in 2016, followed by adjuvant chemotherapy (pT3N1). During follow-up, two liver metastases were identified and located: (1) in segment 5 measuring 15 mm, subcapsular, treated by percutaneous radiofrequency; (2) in segment 7 dorsal measuring 33 mm (not amenable to radiology treatment. A robotic resection of the segment 7 lesion was scheduled. Patient was placed in left lateral decubitus position with the right arm suspended and the robotic cart arrived from the patient's head for docking. Four 8 mm robotic ports using the Da Vinci® X robot were used. The ports were placed subcostally; one laparoscopic port was placed in the right iliac fossa and was used by a second surgeon positioned between the patient's legs. A 30°/8 mm optic was used in arm number 3, monopolar scissors was inserted in arm number 4, bipolar forceps was placed in arm number 2 and Cadiere forceps was inserted in arm number A suction/irrigation device and ultrasonic dissector were manipulated through the laparoscopic port by the second surgeon. The right lobe was fully mobilized, and the inferior vena cava was released. Laparoscopic intraoperative ultrasound was performed to delineate the resection margins. A parenchymal transection was carried out using ultrasonic dissector, bipolar forceps irrigated, and monopolar scissors. Selective ligation of small vessels was obtained with clips. The retrohepatic vena cava was laterally injured at the end of procedure and a hand-sewn suture was quickly performed. The operative field was clearly exposed with arm 4, magnification, and stable vision. In addition, there was no visual tremor and suturing of the vena cava was enhanced with the endowrist needle holder. Postoperatively, the patient was admitted to the ICU and ultimately discharged on postoperative day 5. The estimated blood loss was 300 mL and no transfusions were given. An R0 resection was obtained with 1 cm margins circumferentially. The patient is disease free at 15 months with no evidence of recurrent disease on computed tomography.
Conclusions:
The robotic approach seems to facilitate the control of major bleeding during minimally invasive liver resection. The robotic approach was particularly useful for bleeding during a posterosuperior located hepatic lesion. The robotic technique prevented an open conversion during this case to control the bleeding site.
No competing financial interests exist.
Runtime of video: 7 mins 58 secs
