Six-Port Robotic Liver Resection Using Double Bipolar Clamp-Crush Method With Saline Drops: Advancing Safety, Efficiency, and Versatility in Liver Parenchymal Dissection

Robotic liver resection (RLR) faces challenges in parenchymal dissection due to device limitations, necessitating the development of a safe, efficient, and versatile method for its widespread use. We introduce our six-port RLR approach utilizing the double bipolar clamp-crush method with saline drops to overcome these device limitations. This method, combined with robotic bipolar forceps, maximizes the advantages of RLR by leveraging its multi-joint functionality and facilitates the dissection of strong, fibrotic liver tissue through the use of bipolar energy. The assistant surgeon strategically drops saline solution from an electrocautery system onto the operative field, while simultaneously removing crushed tissue, blood, and excess moisture using an endoscopic suction system through two assistant trocars. This process prevents tissue adhesion to the forceps and carbonization while maintaining a moist environment. Hemostasis is achieved using bipolar or monopolar coagulation under these conditions, with multiple hemostatic devices ensuring safety. In our study, RLR was performed on 16 lesions in 13 patients, including two with cirrhosis and portal hypertension. Median blood loss was 27 mL, and no postoperative complications occurred. The forceps were changed a median of four times due to tissue adherence during liver parenchymal dissection, which prevented tissue adhesion and facilitated efficient hepatic resection. Although further advances in instrumentation technology for RLR are needed, we are confident that our method will lower the barriers for many surgeons to adopt robotic liver resection and contribute to its further widespread use. Our six-port double bipolar clamp-crush method with saline drops shows promise for safe, efficient, and versatile liver parenchymal resection in current RLR practice.