Robotic left lateral sectionectomy with the da Vinci single-port system: A case report

Abstract

BACKGROUND

Robotic liver resection has progressively pushed the boundaries of minimally invasive hepatopancreatobiliary surgery. The recently introduced da Vinci single-port (SP) system enables placement of a multiple-channel cannula through a single 2.5-4 cm incision and aims to limit parietal trauma while maintaining the advantages of current multi-port robotic platforms. Here, we report the first Italian case of hepatic resection performed using this platform and summarize the existing literature.

CASE SUMMARY

A 51-year-old woman with a history of breast cancer presented with a 15-mm metastasis in segment II of the liver. Following multidisciplinary assessment, a robotic left lateral sectionectomy was performed using a supra-umbilical 4-cm incision. Docking time was 20 min, and the total operative time was 255 min, with 50 mL of blood loss and 30 min of intermittent hepatic pedicle clamping. No drains were placed. Postoperative pain was ≤ 1 on the Visual Analog Scale, and the patient was discharged on postoperative day 3 without any complications. Histology showed a 12-mm breast cancer metastasis with 2-mm clear margins and good cosmesis.

CONCLUSION

According to published case series and comparative studies, SP robotic liver resections are technically feasible and safe, with reduced postoperative pain, shorter hospital stays, and improved cosmesis. However, current evidence is limited to selected minor resections, and longer follow-up is necessary to validate the oncological outcomes.

Key Words: Robotic liver resection; Single port; Breast cancer liver metastasis; Case report

Core Tip: This case highlights the feasibility and safety of performing a left lateral segmentectomy for a segment II liver metastasis from breast carcinoma performed using the da Vinci single-port (SP) platform, underscoring the potential advantages of SP robotic surgery in complex hepatic resections.

INTRODUCTION

The introduction of robotic platforms has revolutionized surgery, particularly hepatopancreatobiliary (HPB) surgery. The advantages of robotic surgery in HPB procedures are now widely recognized, combining the benefits of minimally invasive surgery with robotic technologies[1-3]. With the advantages of 3D visualization, wristed instrument control, increased dexterity, and integrated energy devices, the robotic platform allows complex surgeries, including liver transplantation, to be performed in a minimally invasive manner[2,4-6].

For many years, the da Vinci multi-port system has been the predominant robotic platform and has improved over time with the introduction of new models. Unlike previous models, the most recent platform is the da Vinci single-port (SP) system, an innovation designed to facilitate complex surgeries through a single incision, further reducing surgical invasiveness[7,8].

In this paper, we aim to share our experience with the new system, including a video of the first liver resection performed in Italy using the da Vinci SP system, the operating room setup (ORS), and key intraoperative technical aspects.

This case report was prepared in accordance with the CARE guidelines.

CASE PRESENTATION

Chief complaints

The patient was a 51-year-old woman with an American Society of Anesthesiologists classification of II and a body mass index of 22.5 kg/m².

History of present illness

The patient underwent annual outpatient oncological follow-ups, which included computed tomography (CT) scans. One of these scans revealed a lesion in the second hepatic segment, which was suspected to be a metastasis.

History of past illness

Four years earlier, the patient had undergone a quadrantectomy of the right breast with sentinel lymph node biopsy, followed by adjuvant chemotherapy and radiotherapy for breast cancer.

Personal and family history

The personal and family history of the patient was unremarkable.

Physical examination

The patient was in excellent general condition, with good vital signs and a normal general physical examination.

Laboratory examinations

The patient’s blood test results, including carbohydrate antigen 15-3 and carcinoembryonic antigen values, were within normal ranges when measured shortly before the oncology follow-up outpatient visit.

Imaging examinations

Computed tomography (Figure 1) and magnetic resonance imaging (Figure 2) revealed the presence of a single metastasis.

Figure 1 Operating room setup.

Figure 2 Access Port Kit^©.

MULTIDISCIPLINARY EXPERT CONSULTATION

The case was reviewed by our oncology board, comprising HPB surgeons, radiologists, interventional radiologists, oncologists, radiotherapists, endoscopists, and gastroenterologists. The board recommended upfront surgery, which in this case consisted of a left lateral liver sectionectomy.

FINAL DIAGNOSIS

Single breast cancer liver metastasis of 12 mm.

TREATMENT

The ORS (Figure 1) is an often underestimated yet crucial step in surgery[9,10]. Correct ORS has been shown to improve efficiency, teamwork, and safety, and decrease interruptions and infections. This ORS was decided upon in agreement with surgeons, anesthetists, scrub nurses, and intuitive clinical specialists.

Docking is a crucial step for the success of robot-assisted procedures, and based on our initial experience, SP docking is faster and easier than multi-port docking. In a multi-port system, the distances between trocars, assisting ports, and the target zone must be carefully calibrated to ensure optimal system maneuverability and effective assistance from the bedside surgeon. With the SP system, these requirements are eliminated, as an incision of 2.5-4 cm is sufficient to position the Access Port Kit^©, a device consisting of a wound protector, a short entry guide, and the access port (Figure 2).

In the SP system, there is no organ targeting as in the multi-port system. However, based on our experience, we have started to perform preoperative organ targeting (POT) using preoperative CT scans (Figure 3). Using this method, we are able to optimize the site of the median incision with good approximation, taking into account the length of the SP instruments and their working angles. These two parameters are crucial because an excessive distance leads to uncomfortable operating conditions for the surgeon at the console, and the working angle may preclude the bedside surgeon from using an accessory laparoscopic trocar. Therefore, we determined that an entry angle of 40°, while maintaining a distance of 40 cm from the farthest target, may be the optimal entry angle.

Figure 3 Preoperative organ targeting.

By analyzing the images in our preoperative surgical meeting, we observed that the lesion was close to the left hepatic vein. Therefore, we decided to perform a left lateral sectionectomy, an intervention of intermediate difficulty, according to the TAMPA classification system[11]. Using POT, we performed a median incision of approximately 4 cm, starting 2 cm above the umbilicus (Figure 4).

Figure 4 Access Port Kit^© incision.

As in any robotic liver resection, the procedure begins with opening the falciform ligament, sectioning the round ligament, performing intraoperative ultrasonography (IOUS) (in this case, confirming the presence of a single secondary lesion), and surrounding the hepatic hilum with a silicone Foley catheter to allow intermittent Pringle maneuvers when necessary. The distinctive feature of the SP system is its ability to provide two types of views: “Below” and “Above”. In these early stages, we recommend using the “Above” setup. We identified the middle hepatic vein using IOUS and marked its course on the Glissonian pedicle using monopolar scissors. For hepatic transection, we moved to a “Below” view and used an extra-Glissonian approach via the umbilical plate (Gate II sec.[12]). Once access to the gate was completed, we again changed the setup to “Above” and started the hepatic transection using the Moisture-Assisted Multiple Bipolar technique[13]. This technique, previously described by Chiarella et al[13], involves transecting the liver parenchyma using saline-irrigated multiple bipolar energy sources. During transection, continuous irrigation of the hepatic parenchyma with saline solution improves electrical conductivity and facilitates effective bipolar coagulation even at lower temperatures. Multiple bipolar activations were delivered simultaneously in the transection plane to ensure precise coagulative ligation of small vessels and bile ducts within the hepatic parenchyma. Subsequent transection of the parenchyma was facilitated using blunt and sharp dissection techniques with selective visualization and ligation of the larger vessels and biliary ducts. The procedure aims to minimize tissue damage and bleeding by providing precise control throughout transection. In this case, we did not insert an additional laparoscopic trocar for suction but instead used the 12-mm port located on the Access Port^©. The vascular pedicles for the second and third hepatic segments and the left hepatic vein were transected with a mechanical stapler, while the other vascular branches were transected using Hem-o-lok^© clips, with both devices applied by the bedside assistant through the 12-mm access channel of the Access Port^©. All details are shown in the Video.

The resected liver segment was then placed in an EndoBag and extracted from the median incision after SP dedocking.

OUTCOME AND FOLLOW-UP

The total duration of the procedure was 255 min, including 20 min of docking time. Estimated blood loss was 50 mL, and hepatic hilum clamping was performed for 30 min. Surgical drainage was not performed. The patient had no postoperative complications and was discharged on the third postoperative day after a follow-up ultrasound. Postoperative pain was assessed using the Visual Analog Scale[14], and the patient never reported values greater than 1 until the third postoperative day, despite the use of patient-controlled analgesia.

On the final histological examination, the lesion was confirmed to be a 12-mm liver metastasis from the breast cancer, with 2-mm clear surgical margins.

At the 3-month outpatient follow-up, the patient was in excellent general condition, reported no problems, and was fully satisfied with the surgical incision.

DISCUSSION

The da Vinci SP robotic system is a significant advancement in minimally invasive surgery. Compared with established multi-port robotic platforms, the da Vinci SP system presents certain technical advantages and limitations that are particularly relevant in hepatobiliary surgery. In multi-port systems, instrument triangulation is achieved by spatially separating the trocars, allowing for a wide range of approaches and robust exposure, particularly during parenchymal transection and vascular control. In contrast, the SP system relies on the intracorporeal articulation of instruments deployed through a single cannula, which may limit external triangulation; however, this limitation is at least partially compensated by the use of fully wristed instruments and an articulated camera.

Maneuverability in SP surgery generally allows for peripheral and anterior liver segments procedures. However, deep or posterior lesions may pose challenging conditions owing to restricted retraction angles and limited countertraction. Thus, exposure depends more on precise preoperative planning, optimal port positioning, and effective use of the third robotic arm. Vascular control can be safely performed in SP procedures in selected cases; however, the absence of multiple assistant ports may limit immediate access for suction, retraction, or rapid bleeding control, increasing reliance on bedside assistants through a single access port.

Although initial experience suggests that SP robotic liver resections can be performed with acceptable perioperative results in highly selected patients, current evidence remains limited to small case reports and isolated publications[15-17]. Therefore, caution must be exercised when interpreting the available data to assess safety, determine relative superiority, or support adoption in routine clinical practice.

Among the larger comparative studies, 304 patients underwent robotic cholecystectomy, of whom 145 were treated using the da Vinci SP system and 159 using the Xi system. In the SP group, mean operating times were slightly shorter (45.7 min vs 49.8 min), docking times were significantly shorter (5.7 min vs 8.8 min, P = 0.024), early postoperative pain was modestly reduced, and hospital length of stay and morbidity rates were comparable[15].

Another comparative study included 30 consecutive patients with chronic cholecystitis or gallstones who underwent robotic SP cholecystectomy or Si single-site robotic cholecystectomy[16]. The mean docking time for the SP procedures was 5.2 min, the mean dissection time was approximately 14.6 min, and the mean operative time was approximately 75.1 min. The average hospital stay was 1.5 days, and both immediate postoperative pain and pain at discharge were significantly decreased. Learning curve analysis for SP cholecystectomy showed that pre-console, docking, and overall operation times diminished with experience, whereas console time remained relatively constant. This suggests that most of the learning curve lies less in performing the surgery itself than in completing all the preparatory procedures.

The technical feasibility of more challenging hepatobiliary procedures has been demonstrated in several case reports. A left lateral sectionectomy performed without an additional port has a docking time of 8 min, a total operative time of approximately 135 min, and an estimated blood loss of approximately 50 mL. In a previous study, the reported pain scores were low (3/10 at the time of discharge, 1/10 on postoperative day 2), the patient was discharged on day 5, and no intraoperative complications occurred[18]. Another study described a left lateral sectionectomy in a patient with intrahepatic duct stones and distal common bile duct stones (combined biliary tract surgery) using the SP system. The docking time was 8 min, and the estimated blood loss was 50 mL. The patient had a good postoperative recovery, was discharged on day 5, and reported a pain (immediate postoperative Numeric Rating Scale) score of 4/10, which decreased to approximately 1/10 by postoperative day 2. A more recent study described the excision of a hepatic tumor via SP left lateral sectionectomy, reporting an intraperitoneal operative time of 49 min, minimal blood loss (approximately 10 mL), no intraoperative complications, slight postoperative pain, and discharge on postoperative day 4.

The overall safety was acceptable in these relatively small and selected series, with minimal severe complications and low rates of conversion. In most SP minor hepatectomy cases, operative blood loss was minimal, hospital stays were typically short (1-5 days), and postoperative pain scores improved satisfactorily. A comparative series evaluating SP and other robotic single-site or multi-port methods has shown a preference for SP procedures in terms of docking and operative times, with modest reductions in immediate postoperative pain and increased cosmetic satisfaction, although long-term oncological results remain scarce.

The advantages of the SP system for hepatobiliary surgery include improved cosmesis through an SP approach, fewer incisions with potentially reduced wound complications, lesser postoperative pain, shorter docking times, enhanced ergonomics with wristed instruments, and the availability of third-arm retraction assistance. The SP platform overcomes the limitations of earlier single-site robotic platforms, such as limited instrument articulation, lack of a third arm, and instrument collisions. The SP system also allows for an easier setup compared with some multi-port systems.

The limitations of this report include case selection bias, as most SP hepatobiliary procedures are performed in patients with small peripheral lesions and good anatomy. Advanced resections, such as those for large tumors near major vascular structures or requiring complex bile duct reconstructions, are rarely reported. One constraint relates to instrumentation: Staplers and certain energy devices are not yet fully optimized for the SP system, and the lack of assistant-port access may restrict exposure, retraction, suction, or immediate bleeding control. Cost and resource utilization have also not been directly quantified for the SP system in hepatobiliary surgery. Oncological outcomes, including negative margin rates, disease-free survival, and recurrence rates, have not been well reported, especially for malignant diseases.

Future studies should include prospective comparative trials of SP vs multiport robotic and laparoscopic approaches in hepatobiliary surgery with universal outcomes such as oncologic results, patient-reported outcome measures of pain and quality of life, cost assessment, and long-term follow-up for malignancy[8,15-19]. SP-compatible instruments such as staplers, energy sources, and retractors need further development to facilitate safer and more effective major resections. Simulation and SP-specific training courses may help reduce early operative inefficiencies. Selection criteria for the SP system in hepatobiliary surgery need to be developed based on lesion size and location, patient anatomy, liver function, and comorbidities to optimize patient outcomes and avoid complications.

CONCLUSION

The da Vinci SP system represents an innovative paradigm shift toward greater minimally invasive capability in hepatobiliary surgery and appears technically feasible in carefully selected cases of minor hepatic resection. The possible benefits include reduced parietal trauma, enhanced cosmesis, and easier docking. At present, it remains unclear whether this technology will prove safer, more effective, or preferable to established multi-port SP systems. Future studies are likely to further clarify its role with respect to oncological efficacy and cost-effectiveness.