C 1 - FLUORESCENCE GUIDED ROBOTIC SEGMENT 8 SUPERIOR LIVER RESECTION. TECHNICAL APPROACH TO SECTORAL INFLOW OCCLUSION

Objectives: Hepatic adenoma a premalignant tumor of the liver commonly seen in young women with hormonal contraceptive use. Complete surgical resection is recommended for adenoma >4cm to reduce the likelihood of harboring hepatocellular neoplasm. Tumors located in difficult to reach liver segments (segment 7,8,4A) often create hesitancy from surgeons to resect, even with a traditional open hepatectomy. In this case, we describe our robotic approach of segment 8 adenoma resection with anatomical inflow vascular control. We also showed a method of portal venorraphy during the hilar dissection.

Methods: A 39-year-old woman presented with symptomatic enlarging 7.8 x 6.5cm hepatic adenoma against the right hemidiaphragm. The mass is mainly located in segment 8 liver dome, which enabled an anatomical inflow vascular control of the right anterior liver sector. The operation began with a partial right lobe mobilization, followed by individual isolation of the right anterior portal pedicle. A portal venorraphy was necessary using a monofilament suture. The right anterior hepatic artery and the right portal vein were then each clamped using a robotic vascular bulldog, showing lines of demarcation bordering segment 5 & 8. Indocyanine green (ICG) fluorescence angiography was performed to confirm the ischemic demarcation lines. Under a temporary right anterior sectoral inflow control, the segment 8 adenoma was resected. At the end of the operation, the reperfusion of the right anterior sector was resumed. A complete ICG fluorescence of the entire liver was confirmed prior to closing.

Results: Final pathology report showed a hepatic adenoma (7.2 x 6.8 x 2.6cm) without any evidence of carcinoma. The postoperative recovery was uneventful.

Conclusion: We demonstrated a robotic technique of difficult liver segment resection under an anatomical sectoral inflow vascular occlusion. The robotic platform enables delicate dissection and vascular repair when necessary within the porta hepatis. We believe that robotic approach provides an alternative method for liver resection of difficult segments.