Surgeon-controlled robotic CUSA technique for liver parenchymal transection

Robotic liver resection provides a stable and magnified operative field; however, parenchymal transection often relies on skilled bedside assistance, limiting console surgeon autonomy and reproducibility. We developed a surgeon-controlled robotic CUSA technique that allows the console surgeon to perform parenchymal transection using a simple, handmade attachment. This study aimed to describe the technique and evaluate its perioperative outcomes compared with the clamp-crush method. Patients who underwent robotic liver resection at our institution between October 2022 and December 2025 were retrospectively reviewed. Parenchymal transection was performed using the clamp-crush technique in the early period and transitioned to the surgeon-controlled robotic CUSA technique in the later period. All procedures were performed by two board-certified expert hepatobiliary surgeons using the da Vinci Xi or hinotori robotic systems. Perioperative outcomes were compared between groups. Continuous variables were analyzed using the Mann–Whitney U-test and categorical variables using the χ2 test or Fisher’s exact test, as appropriate. A total of 44 patients were included: 19 in the clamp-crush group and 25 in the CUSA group. There were no significant differences between groups in sex, diagnosis, background liver function, or tumor location. Major or segmental resections tended to be more frequent in the CUSA group; however, the difference was not statistically significant. Operation time, liver resection time, estimated blood loss, conversion to open or laparoscopic surgery, postoperative complications, length of hospital stay, and R0 resection rates were not significantly different between groups. The surgeon-controlled robotic CUSA technique demonstrated perioperative outcomes comparable to those of the clamp-crush method while enabling surgeon-controlled parenchymal transection. This approach may serve as a valuable technical option for selected robotic liver resections in experienced centers and provides a platform for future comparative and educational studies.