Precision Robotic Glissonean Approach for High-Branching G8 Pedicles in Hepatocellular Carcinoma.

Abstract

Background: Anatomical liver resection benefits from controlling Glissonean pedicles before parenchymal transection to ensure accurate anatomical boundaries. In segment 8, high-branching Glissonean anatomy can hinder identification of the targeted pedicle, increasing the risk of misidentification. A hilum-first, stepwise intrahepatic approach facilitates safe and precise isolation of each ramification. We present a case of robotic S8 segmentectomy for hepatocellular carcinoma (HCC), using a strategy adapted to this anatomical variation.

Methods: An 83-year-old male with HCC in S8 underwent robotic segmentectomy. Preoperative imaging revealed high-branching of G5 from G8 branches. The anterior Glissonean pedicle was first encircled. (1) G5d + G8d and (2) G5v were isolated, enabling identification of G8v and G8d by subtraction. These branches were selectively clamped, and ICG-negative staining guided precise anatomical resection. The robotic system's enhanced dexterity and magnified 3D vision enabled atraumatic handling of these fine branches.

Results: This approach allowed more distal pedicle division than initially planned, preserving 104 mL (10%) of functional liver. Blood loss was 10 mL/kg, and no complications occurred. The patient was discharged on postoperative day 6. Pathology confirmed moderately differentiated HCC (T2N0M0, UICC 8th) with negative margins and no microvascular invasion.

Conclusions: Robotic liver resection enables precise and atraumatic intrahepatic Glissonean dissection, particularly in cases with high-branching Glissonean anatomy. A hilum-first, stepwise approach-combined with real-time ICG fluorescence imaging-offers a reliable method for safely isolating targeted pedicles, thereby enhancing oncological precision and preserving functional liver volume in challenging segment 8 resections.