Robotic Hepatectomy for a Segment V/VI Suspected HCC Lesion with Cholecystectomy and Evaluation by Ultrasound and Excisional Biopsy of a Segment IVb Lesion

Hepatocellular carcinoma (HCC) is the most common primary liver cancer and is associated with high morbidity and mortality. In this case, the patient was incidentally found to have a segment V/VI lesion consistent with HCC and a IVb lesion indeterminate probability of malignancy. He underwent a robotic-assisted hepatectomy for a segment V/VI lesion with cholecystectomy and evaluation by ultrasound and excisional biopsy of a segment IVb lesion. His postoperative course was unremarkable, and he was discharged on postoperative day four. The pathology demonstrated well-differentiated HCC with resection margins negative for carcinoma. This video demonstrates an experienced surgeon’s technique for performing a robotic hepatectomy for a segment V/VI lesion with cholecystectomy and evaluation by ultrasound and excisional biopsy of a segment IVb lesion. It also highlights effective management of bleeding during hepatic parenchymal transection.

Hepatocellular carcinoma; robotic; hepatectomy.

Hepatocellular carcinoma (HCC) is the fourth most common cause of cancer-death worldwide,¹ with overall 5-year survival cited at less than 20%.² In the United States, HCC is often more commonly seen in males (2:1) in the sixth decade of life.¹ While hepatitis B virus (HBV) and hepatitis C virus (HCV) pose as significant risk factors for HCC, the incidence of HCC related to alcohol-associated liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) are on the rise.^1,3,4 While surgical resection remains the mainstay of curative intent treatment, the recurrence-free survival (RFS) at 5-years remains low at approximately 35%.⁵ Current management of HCC involves a combination of surgery and locoregional therapy. The role of immunotherapy is currently being examined in earlier stages of HCC.⁶

A 76-year-old male presented for surgical evaluation of a segment IVb, V, and VI liver lesion found on imaging during work-up for urosepsis. The patient was found to have no prior history of liver disease, normal liver function tests, and normal tumor markers (AFP, CA-19-9 and CEA). Furthermore, the patient did not demonstrate any evidence of impaired liver function or portal hypertension, such as absence of encephalopathy, ascites, GI bleed or varices, thrombocytopenia, or splenomegaly. The decision was made to proceed with a robotic-assisted segment V/VI hepatectomy, with intraoperative evaluation of IVb lesion, possible biopsy, possible microwave ablation. Previous history was notable for BMI 34.21 kg/m² and colon cancer that was diagnosed 14-years prior, which was successfully treated with a left-sided colon resection. The patient was noted to be a former smoker with minimal active alcohol use.

The patient’s abdominal exam was only significant for well-healed incisions from his prior colectomy and tenderness to palpation in the right lower quadrant. Otherwise, the physical exam was largely unremarkable without scleral icterus or jaundice.

The patient underwent upper and lower endoscopy, which did not demonstrate any new or recurrent gastrointestinal malignancies. A multiphase MRI of abdomen and pelvis was obtained, which demonstrated a 3.1-cm tumor in segments V/VI and a < 1 cm lesion in segment IVb lesion (indeterminate probability of malignancy) and findings consistent with steatohepatitis without evidence of ascites or splenomegaly.

HCC is the second most common cause of cancer-death worldwide,¹ with overall 5-year survival cited at less than 20%.² Surgical resection continues to be one of the primary curative treatments for HCC.⁷ On comprehensive meta-analysis, patients undergoing surgical resection had a 5-year overall survival rate of 56%. The recurrence-free survival (RFS) at 5-years is approximately 35%.⁵

Treatment options can be categorized as curative and palliative. While transplantation is the most definitive treatment option, resection has its role. Many patients are not eligible for upfront resection in the setting of extrahepatic disease, anatomical constraints of hepatectomy, poor liver function, or presence of significant portal hypertension. Often, most patients have disease that is too extensive to permit treatment “curative” intent. While outcomes are less favorable, resection can also offer some benefit in patients with multifocal disease or those with major vascular invasion.^8,9

In patients who are deemed surgical candidates, patients can undergo anatomic versus non-anatomic hepatic resections. Anatomic resection involves resection of liver segments. In patients with underlying liver disease, a non-anatomic resection allows for removal of the least amount of disease-free parenchyma to allow for maximization of postoperative liver function.

Given lesions that are consistent with HCC, with normal underlying liver function, we elected to proceed with surgical resection of the segment V and VI lesions. While the lesion in segment IVb could typically be followed without intervention, the decision was made to evaluate the lesion at the time of surgery. At time of preoperative consultation, we discussed that we would also remove the gallbladder and resect or ablate the segment IVb lesion. We elected for a minimally invasive, robotic approach, given the location of the lesions and absence of other contraindications. The patient’s case was discussed at a multidisciplinary tumor board for consensus and was concordant with these recommendations.

In preoperative evaluation for liver resection for HCC, the patient’s underlying liver function must be taken into consideration. Evidence of portal hypertension or liver dysfunction may pose potential contraindications to liver resection. Preoperatively, patients undergoing major hepatectomy should undergo liver volumetry using three-dimensional reconstruction of CT images to calculate future liver remnant volume (FLR). Robotic segmental hepatectomy is relatively contraindicated in patients with several comorbidities including cardiovascular history, respiratory history, obesity, and prior abdominal surgery. This procedure requires an experienced operator.

Hepatocellular carcinoma (HCC) is a formidable disease, one in which the mortality rates closely mirror its incidence rates globally. It is the fourth leading cause of cancer-related deaths worldwide and the fastest growing cause of cancer deaths in the United States.¹ While liver resection is considered the most effective therapy for patients who are not candidates for liver transplantation, disease recurrence remains a significant challenge in management of HCC. It is theorized that subclinical metastases that arise through microscopic vascular invasion and peripheral spread are responsible for early recurrence.

Anatomic versus non-anatomic liver resection for HCC is a widely debated topic. Anatomic resection, or removal of tumors along with corresponding liver segments delineated by Couinaud, was first proposed by Makuuchi in 1985 with the goal of achieving complete excision of tumor bearing portal tributaries and one major branch of the hepatic artery and portal vein.⁶ However, the survival benefit of anatomic resection has not been clear. Some studies report increased overall and disease-free survival following anatomic resection,^10-12 while others have suggested non-superiority of anatomic resection compared to non-anatomic liver resection.^13-15

Multiple studies have examined the use of neoadjuvant therapies (i.e., TACE, TARE, systemic therapies) as bridging agents towards surgical resection or transplantation. While studies have shown that TARE is both safe and effective in downstaging HCC as a bridge to surgery,¹⁶ no randomized control trials have been completed to establish its role as a neoadjuvant therapeutic in early-stage HCC.¹⁷ The therapeutic landscape for HCC continues to grow with advancements in expanding transplant eligibility and immunotherapy as a complement to other therapeutic approaches.

Surgical pathology of liver, nonanatomic segment V and VI, partial resection demonstrated well-differentiated HCC with resection margins negative for carcinoma (pT1b). Surgical pathology of gallbladder demonstrated cholelithiasis. Surgical pathology of the liver segment IVb excisional biopsy demonstrated no evidence of malignancy.

The following instruments were used robotically: fenestrated tip ups, fenestrated bipolar, Cadiere forceps, hook cautery, monopolar scissors, robotic Harmonic scalpel, robotic suction irrigator, Hem-o-Lok clip appliers.

The authors have no relevant disclosures.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.