Minimally invasive liver surgery has recently acquired the surgical robot among the available weapons. In particular, the “Da Vinci” Robot currently represents the operative standard. Liver resections are now increasingly performed robotically. The increased experience has made these robotic procedures ever simpler and safer to perform. In this presentation, we review the basic steps for dealing with a robotic liver resection. The tools available to perform a robotic hepatectomy also occur. However, at the present time, the robotic surgical instruments completely studied and realized for their application on the liver are very few.

1. Gian Luca Grazi
Hepato-Biliary-Pancreatic Surgery
National Cancer Institute Regina Elena
Rome
Robotic minimally invasive approach
Instruments and basic steps

2. Robotic minimally invasive approach - Instruments and basic steps
Company
1 Intuitive Surgical Da Vinci Xi, Da Vinci X, Da Vinci
SP, Ion
Intuitive remains the dominant company in the robot-assisted surgery space with its Da Vinci robots.
2 Medtronic Hugo Limited European market release; offer a multi-quadrant platform for a wide range of soft tissue procedures.
3 Johnson & Johnson Monarch, Velys, Ottava Continues to developing Ottava and entering into the general surgery market with a highly competitive offering.
4 Stryker Mako Mako sales were up 19% year-over-year in Q2 2022
5 Siemens Healthineers’ Corindus CorPath GRX CorPath GRX as the first and only FDA-cleared and CE-marked device for robotic-assisted coronary interventions.
6 Vicarious Surgical Beta 2
Vicarious Surgical continues to progress in developing its Beta 2 robotic surgery platform.
7 Titan Medical Enos Enos robotic-assisted surgery system to become available later this year.
8 Asensus Surgical Senhance Asensus is looking to expand its Intelligent Surgical Unit with plans for a commercial launch of 5 mm instruments for
pediatric clearance, both expected during the second half of 2022.
9 Moon Surgical Maestro The surgeon is still in the operating room, but the system’s arms assist in moving tools and locking them into place.
It could especially be helpful in short-staffed operating rooms.
10 Momentus Surgical Anovo The first and only FDA-authorized surgical robot that features miniature humanoid-shaped arms, with shoulder,
elbow, and wrist joints that provide high dexterity and unprecedented articulation
11 Virtual Incision MIRA MIRA includes a small, self-contained surgical device inserted through a single midline umbilical incision in the
patient’s abdomen. It allows for complex, multi-quadrant abdominal surgeries.
12 Stereotaxis Genesis RMN, Vdrive, Niobe Stereotaxis provides surgical robotics that incorporates magnets for minimally invasive endovascular intervention.
13 Monteris Medical NeuroBlate NeuroBlate uses MRI-guided laser light to ablate (destroy) brain lesion(s) or unwanted tissue.
14 Zimmer Biomet Rosa The integrated solution with pre-operation software through a partnership with Apple, for instance, creates a
different offering in surgical robotics.
15 Smith+Nephew Cori Cori is a compact, fully mobile offering with a 3D intraoperative imaging system and an advanced robotic sculpting
tool. The surgeon uses a pointer to digitally “paint” over the bone surface that needs removal.
16 EndoQuest ELS Endoluminal robotic surgery with zero scars and reduced trauma.
https://www.massdevice.com/16-surgical-robotics-companies-you-need-to-know/

3. Robotic minimally invasive approach - Instruments and basic steps

4. Robotic minimally invasive approach - Instruments and basic steps

5. Robotic minimally invasive approach - Instruments and basic steps
Positioning of the patient on the table

6. Robotic minimally invasive approach - Instruments and basic steps
Docking in da Vinci Robotic Surgery
Camera port is inserted keeping following principles in mind:
1. Should be in line with the target anatomy (TA).
2. Should be at 10-20 cm distance from the TA.
3. Should be in line with the center column of the patient cart.
8 mm da vinci ports are inserted for robotic arms are inserted
keeping in mind the following principles:
1. >8 cm distance between the da vinci ports.
2. 10-20 cm distance should be maintained between the dv
ports and target anatomy

7. Robotic minimally invasive approach - Instruments and basic steps
Positioning of the first surgical assistant

8. Robotic minimally invasive approach - Instruments and basic steps
Basic Instruments (1)
Monopolar
curved
scissors
ProGrasp
forceps
Maryland
bipolar
forceps

9. Robotic minimally invasive approach - Instruments and basic steps
Clip applier
Basic Instruments (2)

10. Robotic minimally invasive approach - Instruments and basic steps
Permanent cautery
hook
Basic Instruments (3)

11. Robotic minimally invasive approach - Instruments and basic steps
Basic Instruments (4)
SynchroSeal

12. Robotic minimally invasive approach - Instruments and basic steps
Basic Instruments (5)
Large needle
driver
Mega needle
driver
Mega SutureCut
needle driver
Large SutureCut
needle driver

13. Robotic minimally invasive approach - Instruments and basic steps
Firefly Fluorescence Imaging

14. Robotic minimally invasive approach - Instruments and basic steps
Laparoscopic Cavitron Ultrasonic Surgical Aspirator

15. Robotic minimally invasive approach - Instruments and basic steps
Perrakis A, J. Clin. Med. 2021, 10(22), 5265

16. Robotic minimally invasive approach - Instruments and basic steps
Future of Robotic Liver Resections
Specific
Possible development of
specific instruments for
liver surgery

17. Robotic minimally invasive approach - Instruments and basic steps
Future of Robotic Liver Resections

18. Robotic minimally invasive approach - Instruments and basic steps
Future of Robotic Liver Resections
Specific
Possible development of
specific instruments for
liver surgery
Independent
New surgical robots

19. Robotic minimally invasive approach - Instruments and basic steps
J Laparoendosc Adv Surg Tech A. 2020;30(11):1177-1182

20. Robotic minimally invasive approach - Instruments and basic steps
Author / «Identification» Year Reference
Ban
«IWATE»
2014
J Hepatobiliary Pancreat Sci (2014) 21:745–753
HepatoBiliary Surg Nutr 2016;5(4):281-289
Hasegawa 2017 Surg Endosc (2017) 31:5356–5363
Kawaguchi, Kokudo, Gayet
«Institut Mutualiste Montsouris» (IMM)
2018 Ann Surg. 2018 Jan;267(1):13-17
Halls, Hilal
«Southampton»
2018 Br J Surg. 2018 Aug;105(9):1182-1191
Tong Y 2018 HepatoBiliary Surg Nutr 2018;7(6):454-465
Difficulty Scores in Laparoscopic Liver Resections

21. Robotic minimally invasive approach - Instruments and basic steps
Score Level 1 Level 2 Level 3 Level 4
Ban
IWATE
Low difficulty
group
(1-3 points)
Intermediate difficulty
group
(4-6 points)
High difficulty
group
(7-9 points)
Expert difficulty
group
(10-12 points)
Hasegawa
Low
(score ≤ 1)
Medium
(score 2-3)
High
(score ≥ 4)
Kawaguchi
IMM
Group I
(wedge resection/
anterior/posterior
tumors;
left lateral
sectionectomy)
Group II
(anterior
segmentectomy;
left hepatectomy)
Group III
(Posterosuperior
segmentectomy;
right posterior sectionectomy;
right hepatectomy,
central hepatectomy,
extended hepatectomies)
Halls
Southampton
Low difficulty
level
(≤ 2 points)
Moderate difficulty
level
(3-5 points)
High difficulty
level
(6-9 points)
Extremely high
difficulty
level
(10-15 points))

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23. Robotic minimally invasive approach - Instruments and basic steps
Ahmad J, HPB. 2021;S1365-182X(21)01709-3. doi: 10.1016/j.hpb.2021.11.014.

24. Robotic minimally invasive approach - Instruments and basic steps
Ahmad J, HPB. 2021;S1365-182X(21)01709-3. doi: 10.1016/j.hpb.2021.11.014.

25. Gian Luca Grazi
Hepato Biliary Pancreatic Surgery
National Cancer Institute “Regina Elena”, Rome, Italy
gianluca.grazi@ifo.it
www.chirurgiadelfegato.it
Robotic minimally invasive approach - Instruments and basic steps