Management of Bleeding During Robotic Hepatectomy in the Cirrhotic Liver

Hepatectomy in the cirrhotic liver is limited by the amount of parenchyma that can be resected and a more challenging parenchymal division due to fibrous scarring affecting the dissection, isolation and control of intrahepatic vascular structures. Compared to the laparoscopic approach, robotic hepatectomy facilitates parenchymal sparing resections with the increased dexterity of its instruments, while the approach to intrahepatic structures without the CUSA dissector, especially in cirrhotic livers, may lead to increased bleeding during parenchymal transection. Additionally, having the primary surgeon at the console requires a recalibration of maneuvers to counter bleeding complications during parenchymal transection. The purpose of this presentation is to show and discuss the troubleshooting of different situations of bleeding during parenchymal transection in cirrhotic livers using a robotic approach. Parenchymal transection is carried out mainly by combining monopolar scissors, vessel sealer device and bipolar forceps for crush-clamping. The control of intrahepatic structures and management of bleeding complications mainly relies on the Pringle maneuver, direct parenchymal compression, bipolar energy and barbed suturing +/- clips. PowerPoint slide presentation with short video clips will be used.