Robotic right posterior sectionectomy for biliary cystadenoma. Description of standardized approach in anatomical liver resection

Objective: With recent advances in surgical technology, minimally invasive liver resection is gradually becoming the gold-standard practice [1,2,4].Biliary cystadenoma is a rare tumor with malignant potential, therefore parenchymal-sparing liver resection is the preferred approach [3,4].Due to its technical challenge, laparoscopic or robotic anatomical right posterior sectionectomy are infrequently performed in daily practice and rarely described in multimedia literatures.Herein, we describe our standardized technique for robotic right posterior sectionectomy.Methods: A 65-year-old woman presented with a complex 5.3 cm multiloculated liver cyst involving segment 6/7.CT scan and MRI revealed multiple enhancing solid mural nodules and thickened septum concerning for neoplasm.Right posterior sectoral portal vein and hepatic artery were ligated to establish inflow control.After an adequate liver mobilization and dissection of hepatocaval confluence, the line of the parenchymal transection was drawn toward the root of the right hepatic vein following a demarcation line.Mapping of the middle and right hepatic veins was undertaken using ultrasonic guidance.Parenchymal division was undertaken under intermittent Pringle maneuver as necessary.The operation was completed with transection of the right hepatic vein using a robotic stapler.Results: The operative time of 5 hours with minimal blood loss.The postoperative course was uneventful.A final pathology report confirmed a 6 cm multiloculated biliary cystadenoma without evidence of invasive carcinoma.Conclusion: Robotic right posterior sectionectomy is technically demanding, however feasible, safe, and reproducible.We believe this technique can provide an alternative method to the conventional open operation for segment 6/7 liver tumor resection.