Robotic Hepatic Parenchymal Transection Techniques: A Choice Between Imperfect Tools.

Regardless of approach, safe and effective parenchymal transection is critical for hepatectomies. In robotic surgery, this can be accomplished via several methods. The authors highlight some of the more common tools and techniques used to transect the liver. The Vessel Sealer Extend is a console-controlled device with bipolar energy, mechanical cutting, full-wristed articulation, and grasping abilities that allow it to replicate the clamp-crush technique while sealing small vessels. However, the jaw is bulky and suboptimal for firm/fibrotic livers. The Synchroseal shares many features of the Vessel Sealer Extend but has thinner jaws, making it easier to advance in firm livers, and lacks a cutting blade, relying instead on a cut electrode to divide tissue. Proteinaceous char can accumulate on the jaws, impairing its effectiveness, but intermittent irrigation can mitigate this. The robotic Harmonic Scalpel coagulates, transects, and precisely dissects parenchyma. However, it is limited in length and lacks wristed articulation. Ultrasonic surgical aspiratory devices allow for precise, atraumatic dissection around vasculobiliary structures, but no robotic-integrated versions currently exist. Therefore, application of this technology in robotic surgery requires an experienced bedside assistant operating the laparoscopic version while the console surgeon uses robotic instruments to coagulate, clip, and divide larger structures. The dual bipolar technique is useful for spot coagulation and dissection but has limited transection ability. It often is an adjunct to other transection techniques. Several methods exist for robotic parenchymal transection, and although none are perfect, they can be combined for safe and effective transection.