Hepatectomy, cholecystectomy, and biliary reconstruction


Malignancies of the hepatobiliary system can only be cured by resectional treatment, despite the advent of modern chemotherapeutic agents. Ablation and liver transplantation can provide a cure for certain liver cancers, but they are limited by size of lesion, total number of lesions, and donor organ shortage, respectively. The latter is predicted to worsen with rising rates of obesity and nonalcoholic fatty liver disease (NAFLD) induced cirrhosis. Perfecting the technical performance and clinical results of hepatobiliary resection is key to improving survival for patients with these diseases.

Open hepatobiliary surgery comes with high postoperative morbidity, limiting its application in elderly patients, who often present with significant preoperative medical comorbidities. However, significant reductions in postoperative morbidity can be attained through a minimally invasive surgery (MIS) approach, when appropriate expertise is available. Although, laparoscopic resection is possible, the robotic approach offers superior dexterity, seven degrees of freedom, tremor filtration, and three-dimensional (3D) stereoscopic visual input. These elements allow a significantly greater number of hepatobiliary resections to be undertaken and maintained in an MIS fashion, avoiding the higher morbidity and mortality of an unplanned conversion to an “open” approach. Certain features may render an MIS approach inadvisable, particularly when vascular resection and reconstruction are required; nonetheless, an increasing number of resections can be tackled robotically when careful preoperative imaging, patient selection, and intraoperative finesse are employed by experienced hands.


  • Anatomical hepatectomy

  • 1.

    Diagnostic laparoscopy to stage and exclude possible extrahepatic metastasis

  • 2.

    Liver mobilization: Division of falciform, coronary and triangular ligaments, and dissection of the hepatocaval junction

  • 3.

    Dissection at the hepatoduodenal ligament and division of inflow structures

  • 4.

    Parenchymal transection along the ischemic demarcation line and intrahepatic division of the hepatic duct

  • 5.

    Stapled transection of the right or left hepatic vein

  • 6.

    Specimen removal

  • Radical cholecystectomy

  • 1.

    Diagnostic laparoscopy to stage and exclude possible intrahepatic and extrahepatic metastasis

  • 2.

    Division of the falciform ligament to the hepatocaval junction

  • 3.

    Portal lymphadenectomy

  • 4.

    Division of the cystic duct and cystic artery after skeletonization

  • 5.

    Ultrasound guided parenchymal transection of segment 4B and 5

  • Biliary resection and reconstruction

  • 1.

    Diagnostic laparoscopy to stage and exclude possible intrahepatic and extrahepatic metastasis

  • 2.

    Division of the falciform ligament to the hepatocaval junction

  • 3.

    Kocherization of the duodenum

  • 4.

    Portal lymphadenectomy

  • 5.

    Division of the distal common bile duct

  • 6.

    Cephalad dissection toward the common hepatic duct and biliary bifurcation

  • 7.

    Division at the right and left hepatic ducts and en-bloc specimen extraction

  • 8.

    Intraoperative cholangioscopy to the left and right hepatic ducts

  • 9.

    Roux-en-Y hepaticojejunostomy reconstruction

Indications and contraindications for robotic hepatobiliary surgery

The patient must have the cardiopulmonary resilience to tolerate a 4- to 8-hour operation under pneumoperitoneum. Tumor invasion into a major hepatic vein is not a contraindication, as long as negative margins are attainable with resection. Vascular reconstruction with a patch or interposition conduit for inferior vena cava (IVC) involvement is an indication for an open approach. If R0 resection is attainable with a side bite of a major hepatic vein without narrowing the lumen significantly, the resection can proceed robotically as long as adequate experience and technical expertise are available. The presence of nodal disease beyond the tumor’s expected lymphatic drainage basin (N2) or metastatic disease (M1) is considered a contraindication to resection. In addition, an adequate future liver remnant must be preserved (>20% in normal liver, >30% in postchemotherapeutic liver, and >40% in cirrhotic liver) to avoid posthepatectomy liver failure (PHLF). Alternatively, two-staged hepatectomy with portal venous occlusion and embolization can be employed to achieve interval liver hypertrophy, making the operation safer. A set of guidelines is available in Table 57.1 .

TABLE 57.1

Contraindications to Robotic Liver Resection


  • Severe portal hypertension (platelets <100,000/μL, extensive varices, uncontrolled ascites)

  • Inadequate future liver remnant (<25%–30% for healthy, noncirrhotic, nonobese patients)

  • Total bilirubin >1.5 mg/dL in a cirrhotic patient (unless due to obstructive tumor)

  • Unresectable disease (metastasis, retroperitoneal or paraaortic lymphadenopathy)

  • Nonreconstructable vascular invasion


  • Isolated reconstructable vascular invasion— consider open technique or neoadjuvant therapy depending on tumor pathology

Preoperative assessment

Our preferred imaging modality is a triple phase 1 mm cut computed tomography (CT) of the abdomen and pelvis, with regular CT of the chest to complete staging. This is especially important for defining vascular anatomy and potential vascular invasion by the tumor. An MRI with adequate arterial, portal, and systemic venous phases is an acceptable alternative for intrahepatic lesions, particularly in the presence of renal disease to avoid contrast nephropathy. A tissue diagnosis of the liver lesion is often unnecessary; by synthesizing the data from the patient’s demographics, symptomatology, presence of cirrhosis, lesion morphology, and contrast enhancement patterns, we are able to forgo the need for preoperative liver biopsy in greater than 95% of cases, thereby avoiding needle tract seeding which can be a source of cancer recurrence.

We utilize a well-reconstructed thin-cut CT scan to permit 3D liver reconstruction with volumetric analysis to prevent PHLF, a devastating and often fatal complication. A detailed discussion on preventing PHLF is beyond the scope of this chapter; however, along Makuuchi’s decisional algorithm, we are very selective in performing a major hepatectomy in a patient with a total bilirubin greater than 1 mg/dL or evidence of significant portal hypertension (ascites, platelet count <100,000 per microliter or large abdominal varices). In patients with an obstructive cholangiocarcinoma, we preoperatively decompress the future liver remnant side by endoscopic retrograde cholangioscopic (ERC) stenting or interventional radiologic (IR) guided external percutaneous transhepatic biliary (PTB) drainage to reach the goal of total bilirubin less than 3 mg/dL.

In cases of liver lesions smaller than 3 cm in size at a favorable location, we will offer upfront robotic resection over ablation, despite more recent data suggesting that ablation approaches resection in terms of tumor recurrence risk. We are more confident in attaining cure by acquiring pathologic confirmation via negative margins (as opposed to via ablation), conforming to the current recommendations for liver cancer treatment. We utilize ablative methods for patients who cannot tolerate loss of any parenchyma or a prolonged operation under pneumoperitoneum. This often includes patients with background liver cirrhosis in the Child-Pugh Class B category. Additionally, lesions less than 3 cm in a deep, unfavorable location, particularly in those who require maximal parenchymal salvation, should be best treated with ablation. Selection criteria are not absolute but must be applied on a case-by-case basis ( Table 57.2 ). Cardiopulmonary risk stratification and optimization considering patient age, frailty, and extent of resection are very important preoperative steps to ensure safe overall outcomes ( Table 57.3 ).

TABLE 57.2

Factors Determining Ablation Versus Resection

Factors Favoring Ablation Factors Favoring Resection

  • Inadequate future liver remnant

  • Frail cardiopulmonary physiology

  • 3 cm or smaller

  • Central “deep” lesion

  • Adequate future liver remnant

  • Resilient cardiopulmonary physiology

  • 3 cm or larger

  • Peripheral lesion

TABLE 57.3

Guidelines to Obtaining Cardiopulmonary Risk Stratification

Age Major Liver Resection Minor Liver Resection
Age ≥50 years Necessary Necessary
Age <50 years If one or more cardiovascular comorbidities (hypertension, hyperlipidemia, diabetes mellitus) Not necessary

Operating room and port setup

See Tables 57.4 and 57.5 for special equipment required and Fig. 57.1 for operating room setup.

TABLE 57.4

Robotic Liver Surgery Instruments

Arm 1 Energized bipolar forceps
Arm 2 30 degree camera
Arm 3 Monopolar hook, scissors, or bipolar vessel sealer; limited stapler use
Arm 4 Bowel grasper

TABLE 57.5

Nonrobotic Liver Surgery Equipment

  • Multiple 3-0 and 4-0 barbed and nonbarbed polypropylene sutures

  • Multiple 2-0 silk ties and sutures

  • Hem-o-lok clip applier × 2 with multiple clips

  • Bedside assistant:

  • Laparoscopic suction/irrigator

  • Laparoscopic needle driver for insertion and removal of sutures

  • Laparoscopic “alligator” grasper for small specimen extraction

  • 28 Fr chest tube, vessel loop, and bulldog clamp

Fig. 57.1

Robot Liver Surgery Port Placement.

Patient preparation and positioning

Starting from 2016, we began to utilize the Intuitive Surgical Inc. da Vinci robotic platform (Intuitive Surgical, Sunnyvale, CA) to undertake minimally invasive hepatobiliary resections. We have previously published our operative setup and initial outcomes from our tertiary hepatobiliary center, but the following is a more detailed explanation.

Patients are positioned supine on the operating table and induced with general endotracheal anesthesia. A central venous catheter and a radial arterial line are placed to facilitate central venous pressure (CVP) monitoring during liver parenchymal transection (<5 mm Hg) and to guide intraoperative resuscitation, which includes judicious fluid administration to prevent excessive hepatic venous bleeding. We also ask anesthesia to eliminate the postexpiratory positive pressure (PEEP) to further reduce the hepatic venous pressure, thus achieving optimized hemostasis during parenchymal transection.

Stages of the procedure

Port placement and robot docking

An 8-mm trocar is inserted through the umbilicus for the robotic camera. This is performed by an open cut-down technique. Two 8-mm robotic ports are utilized at the right and left midclavicular lines in parallel. The left mid-clavicular port is often upsized by the bedside assistant to a 12-mm port to accommodate a robotic stapler. A fourth 8-mm robotic port is placed along the left anterior axillary line at the level of the umbilicus. This port arrangement functions well for left anatomical hepatic lobectomy, left-sided nonanatomical resection, central hepatectomy, and biliary resections with/without reconstruction ( Fig. 57.2 ). However, for right, posterosuperior, and particularly dome lesions, a shift of the port arrangement approximately 1 inch to the right is necessary and the umbilicus is not utilized. For lesions in segment 7/8 that undergo resection, we superiorly displace the left-sided ports in a curvilinear orientation in an attempt to improve triangulation; otherwise, these ports are placed at approximately the same level. An Advanced Access Gelport (Applied Medical, Rancho Santa Margarita, CA), placed between the right midclavicular line and the umbilicus, is used for bedside suctioning and specimen extraction. An AirSeal (CONMED, Utica, NY) port is inserted through the Gelport for insufflation and smoke evacuation (see Fig. 57.1 ). The bedside assistant utilizes the Gelport by crossing the laparoscopic devices to permit multi-instrument laparoscopy from a single-entry point.

Fig. 57.2

Robotic Liver Surgery Operating Room Setup.

Reverse Trendelenburg (15 degrees) with a slight left tilt (5 degrees) position is then applied. The da Vinci Xi robotic surgical system is docked over the patient’s right shoulder and paired with the operating table to allow for intraoperative bed motions. The bedside assistant stands to the right of the patient, opposite from the scrub nurse (see Fig. 57.2 ). The arms are docked 1 to 4 from the patient’s right to left. An energized bipolar forceps (arm 1), 30-degree camera (arm 2), monopolar cautery hook (arm 3), and bowel grasper (arm 4) are utilized.

Liver mobilization: Dissection of falciform ligament, hepatocaval junction, and division of coronary and triangular ligaments

The operation begins with a diagnostic laparoscopy, which occurs concurrently with port placement to prevent unnecessary additional incisions should carcinomatosis be found. Once the robot is docked, an ultrasound probe is inserted through the Gelport and controlled by the console surgeon to perform a thorough search for additional intrahepatic lesions and ensure that the correct operation proceeds. The presence of metastasis or additional lesions that would require resection of more hepatic parenchyma and compromise an adequate future liver remnant may lead to a change in the operative strategy or abortion ( Fig. 57.3 ). The course of the right, middle, and left hepatic veins are also marked so that they can be used as landmarks of resection and their encounter during later parenchymal division is anticipated in a controlled manner. This way, the surgeon can significantly reduce blood loss and operative time wasted trying to control profuse bleeding ( Fig. 57.4 ).

Fig. 57.3

Intraoperative Ultrasonography Identifying a Tumor in Segment 7.

Fig. 57.4

Intraoperative Ultrasonography Identifying the Notch Between the Right and Middle-Left Hepatic Veins.

The falciform ligament is divided from the parietal peritoneum up to the hepatocaval junction ( Fig. 57.5 ). The overlying parietal peritoneum is carefully dissected with monopolar hook cautery, which can act as a right angle and then sharply divide translucent tissue, taking care not to injure the major hepatic veins or IVC beneath. The notch between the right hepatic and middle-left hepatic veins is exposed and marked ( Fig. 57.6 ). In a minimally invasive liver resection, the hepatic veins are not transected at this time. Instead, they are transected at the final end of the parenchymal division after adequate isolation is achieved.

Fig. 57.5

Right Hepatic Vein Partially Exposed Overlying Peritoneum Dissected Off.

Fig. 57.6

Left Hepatic Vein Partially Exposed With Overlying Peritoneum Dissected Off.

From the peripheral edge of liver segment 2 or 6, monopolar hook cautery divides the peritoneal and diaphragmatic attachments to the liver at the left and right triangular and coronary ligaments for a left or right hepatectomy ( Fig. 57.7 ). A right hepatectomy requires mobilization of the right posterior retroperitoneal attachments, exposing but not dividing the Gerota fascia ( Fig. 57.8 ). This dissection should connect in a cranial direction toward the prior dissection and exposure of the right hepatic vein at the hepatocaval junction. If a hemihepatectomy (+caudate lobectomy) is envisioned, the retrohepatic IVC needs to be exposed and the short hepatic veins will require dissection and individual ligation with clips ( Fig. 57.9 ). The monopolar hook can perform “right-angle” action but must absolutely not be used for energy division of these short veins to avoid potentially catastrophic caval bleeding. Mobilization for a left hepatectomy carries the dissection at the hepatocaval junction medially toward the right crus, dividing the fibrous appendix of the liver and Arantius ligament ( Fig. 57.10 ).

Sep 9, 2023 | Posted by in GENERAL SURGERY | Comments Off on Hepatectomy, cholecystectomy, and biliary reconstruction

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