The round and falciform ligaments are divided using hook cautery (Fig. 15.3), exposing the anterior surface of the hepatic veins.

The ligamentous attachments of the right liver are dissected. With the patient’s right side up, the gallbladder fundus is retracted superiorly via a grasper in the LUQ port, and the right lobe of the liver is retracted anteriorly using a closed grasper in the right mid-abdominal port. The hepatic flexure is dissected and the colon is reflected inferiorly. Attachments to the duodenum are also dissected from the liver as necessary. Gerota’s fascia, once exposed, is pushed posteriorly using another closed grasper. A cautery device is used to divide the right triangular and coronary ligaments up to the right hepatic vein/inferior vena cava (IVC) (Fig. 15.4).

Laparoscopic ultrasound of the liver is performed via the 12 mm assist port to confirm anatomy and ensure that the procedure will include the pathology that is anticipated.

The robot is docked. The camera arm should be aligned with the patient’s head, and the camera is docked in the camera port (Fig. 15.2). Arm 1 docks in the robotic port to the left of the umbilicus, Arm 2 docks in the right robotic port, and Arm 3 docks in the LUQ port.

Cholecystectomy and portal dissection. With a grasper in the robotic Arm 3 retracting the fundus of the gallbladder superiorly, a bipolar grasper in robotic Arm 2 holds lateral retraction on the infundibulum while a robotic hook in Arm 1 dissects around the cystic artery and duct. After identifying the critical view, the cystic artery and duct are clipped and transected (as with a laparoscopic cholecystectomy) via the 12 mm assist port. The gallbladder should stay in situ until the portal dissection is completed. It should be noted that this is different from the open technique…in the open technique, the gallbladder is separated from the gallbladder fossa, but the cystic duct remains intact to allow for a cholangiogram to be performed after hepatic parenchymal transection. While maintaining superior retraction of the gallbladder, portal tissue is retracted laterally via the bipolar grasper in robotic Arm 2. The hepatoduodenal ligament is dissected using hook cautery in robotic Arm 1. The right hepatic artery (HA) is identified and defined (Fig. 15.5). If space allows, this is stapled using a vascular load, roticulating stapler through the 12 mm assist port. Otherwise, this can be tied robotically, clipped with the robotic clip applier via robotic Arm 1, and then transected. Next, the right portal vein (PV) is identified and defined. A silk tie is placed around it (this is not tied), and robotic Arm 2 retracts this tie superolaterally to expose the full length of the vein (Fig. 15.6). A vascular load, roticulating stapler is used through the 12 mm assist port to ligate and transect the right portal vein. The right hepatic duct (HD) is identified and defined. A dissecting forceps may be more beneficial than the hook if the duct is deep within adjacent tissue. The right HD is tied distally and then transected proximally (Fig. 15.7). It is important to identify bile coming from the proximal duct. Once bile is identified, the proximal duct can be clipped to maintain a clean field. The free, distal end of the right HD is doubly clipped to prevent leak. Note that during this time, the two assist ports are used to help expose as necessary. Once the portal dissection is completed, the gallbladder is dissected from the gallbladder fossa, placed in a laparoscopic bag, and removed from the abdominal cavity.

The IVC is dissected. For exposure, the gallbladder fossa is gently pushed superiorly using a surgical sponge sponge within a grasper via robotic Arm 3 (Fig. 15.8). Suction is used in the 12 mm assist port to push the right kidney posteriorly. The IVC is exposed. The liver is mobilized from the inferior vena cava by identifying and ligating short hepatic veins. Using a dissector in robotic Arm 2 and cautery in robotic Arm 1, the short hepatic veins are ligated with clips and silk ties, as appropriate. To clip, a robotic clip applier is passed through robotic Arm 1. To tie, a needle driver in robotic Arm 1 is used with a robotic dissector in Arm 2. This is done up to the right hepatic vein.

The parenchyma is transected. All retracting instruments are removed, allowing the liver to drop. The line of transection is defined using hook cautery, following the line of demarcation on the liver’s anterior surface. Ultrasonography is repeated to ensure again that the pathology will be included in the point of transection. Figure-of-eight stitches using 0-size absorbable suture are placed on either side of the line of transection, and these are retracted to either side using robotic ports (Fig. 15.9). The parenchyma is coagulated, placing clips when appropriate. Progress is made along the line of transection until the right hepatic vein is encountered. Using a vascular load, roticulating stapler through the 12 mm assist port, the right hepatic vein is stapled intraparenchymally. The remaining parenchyma is divided as necessary.

The specimen is collected using a laparoscopic bag. Hemostasis on the resection bed of the liver is ensured. The proximal falciform ligament is tacked to the diaphragm with a single figure of eight stitch. The robot is undocked, and the specimen is removed from the abdominal cavity. Fascia is incised at the extraction point as necessary.

The abdomen is closed. Laparoscopic equipment is used to remove ports under direct visualization and close fascia. Fascia at the extraction site may need to be closed from the outside in standard manner. The skin is closed.

Access is gained to the abdominal cavity via a 5 mm port ideally in the LUQ, and pneumoperitoneum of 12 mmHg is created (Fig. 15.10).

A 5 mm, 30° scope is used to visualize additional port placement, including a supraumbilical, 12 mm port for the camera; a right, subcostal robotic port at the midclavicular line; a left, robotic port at the anterior axillary line; a 12 mm assist port 8–10 cm inferolateral and to the right of the camera port; and a 5 mm assist port 8–10 cm inferolateral and to the left of the camera. The scope is changed to a 10 mm, 30° scope for use in the camera port, and the LUQ port is changed to a robotic port.