Robotic Resection of Large Central Hepatic Tumor: Technique of Juxta-Hilar Tumor Dissection Off Anterior Glissonean Pedicle Sheath.

BACKGROUND

Robotic liver surgery enables precise, parenchyma-sparing resection of centrally located hepatic tumors involving critical hilar structures. Focal nodular hyperplasia (FNH), although benign, may require resection in symptomatic or enlarging lesions.

PATIENT AND

METHODS

A 24-year-old woman with biopsy-proven FNH presented with progressive right epigastric pain and tumor growth from 4.4 cm to 7.0 cm. Preoperative imaging demonstrated a centrally located lesion abutting the right anterior Glissonean pedicle without evidence of major vascular invasion, making preservation of uninvolved hepatic parenchyma a principal operative objective. She underwent robotic partial central hepatectomy (segments 4A, 4B, 5, and 8) with cholecystectomy, with intraoperative indocyanine green (ICG) cholangiography used to delineate biliary anatomy near the Glissonean pedicles. The robotic approach was selected to facilitate stable hilar exposure, meticulous juxta-hilar dissection, and controlled parenchymal transection adjacent to the biliary bifurcation while avoiding unnecessary extended hepatectomy. Selective vascular stapling was utilized only for isolated segmental inflow and outflow structures encountered during transection, while preserving the major hilar vasculature and surrounding functional liver parenchyma.

RESULTS

The procedure was completed in 3 h with 100 cc estimated blood loss and no complications. She was discharged on postoperative day 3. Final pathology confirmed complete resection, and at 1-year follow-up, she remained symptom-free with no evidence of recurrence.

CONCLUSIONS

This case highlights the feasibility of robotic central parenchyma-sparing hepatectomy for lesions in close proximity to critical hilar structures, demonstrating how enhanced robotic dexterity, stable visualization, and fluorescence guidance can facilitate safe dissection and excellent perioperative outcomes in anatomically challenging tumors.