Incorporating the Laparoscopic Cusa into Robotic Hepatectomy

Abstract

Introduction: Robotic technology has many advantages over laparoscopy including improved optics and instrument dexterity. However robotic hepatectomy has been slow to gain acceptance and one reason is the perceived inability to use the Cavitron Ultrasonic Surgical Aspirator (CUSA) during parenchymal transection. We provide a technical description for the successful incorporation of the laparoscopic CUSA during robotic hepatectomy.Methods: Surgical technique: Robotic ports are placed across the upper abdomen. The camera is placed in line with the liver hilum. An additional 12mm assist port is placed between the camera port and the most lateral right sided port for use of the CUSA during parenchymal transection. The liver is divided with the use of the laparoscopic CUSA. Intraparenchymal vascular and biliary structures are divided with a combination of the robotic vessel sealer and hem-o-lok clips. Larger hepatic veins are stapled with the robotic stapler. Results: Robotic hepatectomy was performed on 54 patients from September 2018 to December 2020 at our institution with the use of the laparoscopic CUSA. Major hepatectomy (>= 3 segments) was performed in 21 (39%) cases. Median EBL was 285mL (15-2200) and 5 (9%) of patients required blood transfusion. Major morbidity (grade III) occurred in 2 (4%) cases including 1 biloma and 1 pneumothorax. The median LOS was 2 days (1-9) and 30-day readmission was 7%. The 90-day mortality was 0%. Conclusions: Liver transection with the CUSA improves the visualization of intrahepatic vascular and biliary structures, reducing hemorrhage and biliary morbidity during robotic hepatectomy