Fully robotic liver transection using harmonic ACE curved shears: technical refinements, early insights, and challenges during the initial phase of robotic program implementation.

BACKGROUND

Robotic liver surgery is rapidly evolving, but its standardization is limited by the lack of dedicated instruments for parenchymal transection. The Harmonic ACE Curved Shears are widely used; however, guidance on optimizing their use and a clear assessment of their advantages and limitations are lacking. This study evaluates the strengths and limitations of this transection method in a newly established robotic hepatopancreatobiliary (HPB) centre, based on surgical outcomes.

METHODS

Patients undergoing robotic liver resection between February and December 2024 were included. Parenchymal transection was performed using a "one-surgeon, fully robotic technique" with the Harmonic ACE Curved Shears. Intraoperative and postoperative data - including operative time, blood loss, clamping time, complications, and hospital stay - were prospectively collected and retrospectively analyzed.

RESULTS

Sixteen robotic hepatectomies were performed (15 minor, 1 major) for benign and malignant conditions. Median blood loss was 25 mL (IQR 0-325), mean operative time 341±120 minutes, and median clamping time was 8 minutes (IQR 0-56). Fifteen patients had an uneventful postoperative course, with a mean hospital stay of 5.2±2.8 days. One patient developed a grade B biliary fistula. No 30-day mortality or readmissions occurred.

CONCLUSIONS

The fully robotic technique using Harmonic ACE Curved Shears is safe, effective, and reproducible. It replicates the crush-clamp technique and mimics other transection tools, facilitating precise dissection of biliary and vascular structures while minimizing blood loss and bile leaks. This approach may be particularly valuable in newly established robotic HPB centers, helping to achieve satisfactory surgical outcomes even during the early phase of program implementation. Nevertheless, these promising results require confirmation in larger cohorts and further studies, particularly to validate the safety and effectiveness of this technique in major hepatectomies and in procedures of greater complexity.