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

CHAPTER 1

I am Rushin Brahmbhatt, I'm an HPV surgical oncologist at Penn State here in Hershey, Pennsylvania. Today we have a case of a 76-year-old gentleman who has no history of liver disease, but he presented with urosepsis, and in the workup of that had a CT scan of his abdomen, which showed a lesion in the right side of his liver. He was referred to our hepatologists for further workup, and the patient was evaluated, was found to have no history of liver disease. His underlying liver function was otherwise very normal. He does have a history of colorectal cancer for which he underwent a left-sided colon resection in 2010, and so he's about 14 years out from his colon cancer and he has no other history of malignancy. He underwent upper and lower endoscopies to rule out any recurrence of any GI malignancies or any new GI malignancies that might be metastatic to the liver. And then he underwent an MRI. The MRI demonstrated about a 3.1-centimeter tumor in segment V and VI of the liver. His tumor markers at that time were normal, so his AFP in particular, which is one that we evaluate for specifically hepatocellular carcinoma, was normal. His CA 19-9, which can be indicative of biliary tract malignancies, was also normal. And his CEA was normal. The appearance of the lesion on the MRI was very consistent with hepatocellular carcinoma even though this patient had no history of cirrhosis. The lesion in his right lobe in segment V and VI measured about 3.1 centimeters and was LI-RADS 5, and so consistent with presence of hepatocellular carcinoma. And then a second lesion was found in segment IVb, which measured under one centimeter and was LI-RADS 3 tumor, which is an indeterminate tumor, which can either be followed, but in this situation we were going to be operating on his liver and so I was in a position to be able to evaluate that tumor at the same time. And so I spoke with the patient preoperatively about the fact that we had a certain diagnosis of hepatocellular malignancy in segment V and VI of the liver and a possible HCC in the segment IVb of the liver. And I discussed with him liver resection. In his case in particular, his tumor was amenable to a minimally invasive approach, in particular a robotic approach. It was in segment V and VI, kind of low in the inferior aspect of the right lobe of the liver, and was amenable to a robotic approach. And so I discussed that with him, that I would proceed with the robotic resection of this mass in segment V and VI, a robotic cholecystectomy, as well as evaluation by ultrasound of the lesion in segment IVb with either possible biopsy and possible microwave ablation as well as possible excisional biopsy should that be required. In the preoperative assessment of patients who are to undergo liver resection for hepatocellular carcinoma, most important components are to assess underlying liver function and the presence of portal hypertension, which represents somewhat potential contraindications to proceeding with liver resection. In his case, he had no evidence of liver dysfunction in his past. He had some possible steatohepatitis as evident on his MRI, but he did not have any evidence of encephalopathy, ascites, or GI bleed or varices, and he had no evidence of thrombocytopenia or splenomegaly, which may indicate potential portal hypertension that is undiagnosed and could increase the risk around liver resection. The main components of liver resection are mainly inflow control, outflow control, and parenchymal transection. In this setting, the patient had a tumor which was in segment V and VI. Primarily this would be resected with a non-anatomic resection. And in my experience, the non-anatomic resections tend to be slightly more difficult only because inflow and outflow control prior to parenchymal transection is not as definitively obtained as it would be during a formal anatomic liver resection. The major steps of this operation are to establish ports and the port placement is very important, in particular because parenchymal transection method that I use is the robotic harmonic scalpel, and the harmonic scalpel for the robot in particular, you lose a degree of freedom because you don't have the articulation of the wrist. And as a result of that, I have to ensure that the harmonic scalpel is positioned in a way that is in the plane of the parenchymal transection. And so for a segment V and VI resection, I plan a wedge where there would be a plane that is pointing towards one port, and then the second plane would be pointing to the other working port. And that would allow me to basically triangulate that parenchymal transection. The other key component of this is the Pringle maneuver to reduce the blood loss during the parenchymal transection. In minimally invasive liver resections, there are multiple methods to obtain a Pringle maneuver. The one that I find easiest in the robotic setting is to use what's called a Huang's loop method, which is basically using a 16-French Foley catheter and encircling the hepatoduodenal ligament, which can then be controlled by robotic means rather than requiring a bedside assistant to control the application and removal of a Pringle at that time. So in terms of parenchymal transection, there are multiple different methods of parenchymal transection. There's not one that is definitively excellent in the setting of robotic liver resection. I've tried many different methods with the robot and I've found that using the harmonic scalpel seems to be the easiest method. In particular, I use it to go through the parenchyma in a fashion to leave the pedicles behind, either the hepatic veins or the portal vein or portal triads behind, so that I can apply either a clip or stapler to those. And I prefer to avoid stapled hepatorrhaphy.

CHAPTER 2

You know the setup. I like to do split legs because the assistant has a little bit more room in between, and this draping allows us to make a nice Pfannenstiel incision for, a small Pfannenstiel incision for extraction. And I just like to leave those kind of coiled up at the bottom there. All right, marking pen, please. So I always mark out my open incision. In this patient, he has a previous midline, right? But I also mark out the right subcostal. Hopefully in a robotic case where you're going to convert, a midline laparotomy should be sufficient even for a very right-sided tumor, right? Because hopefully by the time we're getting to that point, I've mobilized the liver sufficiently. Ultrasound now or do you want me to wait? The ultrasound, you can go ahead and pass it off now, thank you. So usually it's about one of my fingerbreadths, two of your fingerbreadths, all right? And then when you get out laterally, you always wanna cheat towards the rib slightly. I always try to use the permanent side of the marker here because the Ioban will... That's his previous incision. And then for the Pfannenstiel, I usually choose something that's gonna be at least four fingerbreadths below my anticipated camera sites, but also at least one fingerbreadth above the pubis. I want a stapler to be able to reach where I need to go. His lesion is gonna be right about here, and so a stapler in order to, yeah, get there, will have to be just a little bit higher. Right about here. What we can do is use his old incision site and see if that might be easier for him. And then these ports over here, I always want to cheat low, but I want to keep, yeah, I wanna keep an eye of where that ASIS is. So that's his iliac crest, and that's his ribcage, so I'm gonna go right about here. And then maybe perhaps we'll cheat that one over this way once we get in. Okay. All right, there you go. All right, scalpel, please. Thank you. Incision. So the traditional teaching is always about Palmer's point. I always cheat down, and you know, I've been doing this method of peritoneal entry for some time and so I feel comfortable getting away from the Palmer's point a little bit. But obviously that's the safest location. I'll take the zero degree and camera and the five millimeter. Thank you. All right, can we get the OR lights down, please? Colin, can I have you move that camera down a little bit for me, please? And the patient's previous left-sided colon resection obviously means that I'm gonna be very cautious with this entry. So here we see sub-Q, sub-Q, sub-Q. There's an anterior fascial layer. And some muscle. There we go, now I see that a little bit better. Posterior fascial and peritoneal layers. And I think that's gonna be omental fat there. Gas on, please. Low flow. So Kelsey, I'm looking at both the pressure as well as what's going on on the screen. And the pressure is low. I can tell that there are some adhesions here. The omentum will usually fall away from me like that. At this point I kind of orient my camera so that the - the camera is appropriately oriented. And then when I drop my hand, I'll be able to see kind of free space in the peritoneal cavity, the parietal peritoneum, and down here will be omentum. And then I can see the free space. Can we go high flow, please? 15 high flow. Okay. And once we get to a sufficient pressure here... I'm gonna aim towards the safe free space under the parietal peritoneum and push in until I feel the release of the balloon, and then I'm gonna inflate the balloon. Syringe, please. And so the benefit of this port is that I can visualize peritoneal cavity as I obtain pneumoperitoneum. First thing I do when I get in inside is make sure that there's no injury to underlying structures. All right. Okay, and then we're gonna proceed with our peritoneal evaluation. We see the adhesions, which are as expected. All right. So, not many adhesions to the upper abdomen, which is great. The liver, as expected, doesn't look overly cirrhotic. Okay. All right, we're gonna need the blunt tip LigaSure opened, Colin, so we can take down some of these adhesions. Can you show me where... Where are we down here? Yeah, I think we might be better off putting that 15 port first so we can take down these adhesions safely and then put in the ports over over on the other side. All right, you good, Kelsey? Right there? Right here? Yeah. No, we're gonna do the AirSeal over there. Yeah, sorry, I changed plans. We changed plans slightly here. Aim up towards liver a little bit. There we go. Mm-hmm. Can we hit the AirSeal button? There's some controversy about whether AirSeal increases or decreases the risk of air embolism during liver surgery. All right, can you take that out? And let's use the blunt tip LigaSure to take down some of the adhesions. Going up behind you. All right. So aim down towards the pelvis here. I'm gonna show you where you are. So come on in here. You are gonna be working against the camera. Yeah, you can just take it down for... We're not gonna be able to see it from that side over there. Let me put in another port here. All right, let see here. Just make sure you're low enough, okay? Right there is good. And then aim up towards liver. Just like that. Yep. Hold on one sec. Hold on right there. There we go. Go ahead. Right there. Now aim towards liver completely. There you are. You're gonna have to do this all yourself. Here you go. I would probably switch that. All right, look right here. Look up a little bit. Look at this trocar. There you go. All right. Good. Oh no, this one will. That's the Harmonic that you have to test. Okay. This one should be okay. Go ahead. Mm-hmm. Grasper. I can do it from this side if you're struggling. Okay. Go ahead. Okay, let's look down here. Okay, let's look here. We're far enough away from that. I think it will. All right, knife, please. Thank you. All right. Can I get the other eight-millimeter port? Here we go. Knife, please. I always use a 15 millimeter for my assistant port, which I'm gonna later expand for specimen extraction anyways. In this patient, he has a previous midline, so I'm just gonna use that. Oh, sorry, I needed a balloon port for this one. The 15-millimeter balloon port. Thank you Syringe? All right, can we get 15 degrees reverse Trendelenburg and five degrees right side up? If we could hand off the laparoscopic camera and we can dock the robot?

CHAPTER 3

All right, Kelsey, if you could push this above that screen over there, that'd be great. I would pull it out over to where Colin is and then straight up. Great, thank you. Yes, please. Thank you. Thank you. So this is a very inferior and lateral lesion, and so I know I'm gonna have to really retract that liver over towards the medial aspect of the patient. So that's why I like to put the camera in number two and then use number four to either use the gallbladder or the falciform as a a way to retract the medial liver. Colin, we're gonna aim for two as the camera port. We're coming in with the robot, if you could watch the face. Come in a little bit. There we go. We're gonna target today, Colin, so you can leave it right there. The biggest part about docking the robot, the most important aspect is to get enough distance in the flex between the arms. And then, Colin, we're gonna have to watch that screen over there because the boom is gonna come around. So aim towards the inferior segment VI lesion. A little bit lower, right about there, okay? We're gonna move the robot again, if you could watch the face. If you could flex that arm out to number one, Kelsey. No, you can even flex, you see up here, F-L-E-X, so you can flex that out. All right, can I get tip up, please? Fenestrated bipolar. And then can I get the Cadiere? Here you go. Thank you. And then notice, Kelsey, that the caution tape for the robot, right? Doesn't come on unless the camera is clutched. So now that the camera is clutched, I can safely insert my number three. Okay, if you look straight up almost, it'll be right up there. Danielle, Paige, are you okay? Yes. All right. I'm gonna go to the console. We will need suction for the liver resection. We'll need the robotic suction, please. Robotic suction? Yes, please.

CHAPTER 4

Okay, so I'm just gonna get my bearings to begin with. Make sure my angle of the camera's okay. I'm gonna have two points of traction. One will be this gallbladder, and then there's a LI-RADS 3 lesion underneath the gallbladder, and so I'll be able to use the gallbladder for retraction and then later it'll be coming out as part of the operation. I can also use the base of the falciform to control the liver. Whenever I grab the liver, or sorry, whenever I grab the gallbladder, I wanna make sure that my tips when I'm retracting aren't gonna be facing into the liver. And so many times I'll grab across the cap of the gallbladder like so. And if I need a little bit more tension, I'll turn my tip up 90 degrees so that I can get a little bit more tension on that. And as I retract that, we can see the mass in segment V/VI of the liver here. And likely related to his previous operations, he has the small bowel that's kind of sneaking up into the area up here. We're gonna try to avoid that completely. Can I get hot scissors in number three? So Cadiere out. Thank you. Thank you. And really just taking down these ligaments to prevent retraction injury to the liver during the case. I think this is actually slightly more in segment V than I had anticipated, which means that it might allow a little bit less of this dissection of the right coronary ligament in order to get that up into our view. Okay, can I get Cadiere back in number three, please? Scissors out. Cadiere back, please.

CHAPTER 5

And the first step of this now that I've identified the lesion is going to be to establish a Pringle maneuver, and I use a modification of the Huang loop technique for the Pringle. And so I'm going to try to identify the location of my foramen of Winslow. And then on the other side, I'm going to identify my pars flaccida. I am using my full instrument to assist with that retraction. And I can see caudate lobe right there. And so the Pringle maneuver is going to send... Done by encircling the hepatoduodenal ligament by going through foramen of Winslow and then accessing the lesser sac through the pars flaccida. Can I get the hot scissors back in number three, please? Cadiere out. Hot scissors, please. Thank you. Okay, can I get the Cadiere back in number three, please? Scissors out, and then if I could get the 16-French Foley catheter cut to about 15 centimeters, please? Yes, go ahead and pass it in. And then if I could also get a two-by-two, please. Two-by-twos there. Yep. Thank you. So for my Huang loop Pringle setup, I use a 16-French Foley catheter cut to a length to allow encircling of the hepatoduodenal ligament. I will identify my foramen of Winslow and then pass... The Foley catheter in. And there should really be no tension while passing that. And really I can tell that because I don't get any feedback in terms of tension. I can tell that based on what the Foley catheter is doing as I'm passing it there. Once I pass enough of it... Thank you. What am I hitting with the number one? And I can see my Foley here. Can I get the ProGrasp ready, please? In number three, please. The ProGrasp has an increased strength, and so I'm gonna be able to grasp that Foley on the other side. I just wanna make sure that the duodenum is outta the way for that Pringle maneuver when I do set it. And then I find that there's a potential, though I've never seen it, of some tissue being pinched at that location of the Foley. So I always place a Ray-Tec there for, one, to protect any tissue underneath, but also because if I ever need to release that Pringle quickly or if I'm unable to slide it, I can also just cut that Foley catheter. On that side. And so the Pringle maneuver is all set up there. I'm always gonna pay attention to make sure that that duodenum is out of the way whenever I'm applying that. This allows me robotic control of the Pringle maneuver rather than requiring bedside control of that.

CHAPTER 6

I'm gonna make sure that my retraction is adequate. Now I use the Harmonic for my parenchymal transection, and so I want to try to align the plane of the parenchymal transection with my number three arm, and that'll be the use of this retractor in order to align that properly. Okay. All right, can I have you pass in the ultrasound through the assistant port, please? Just kind of aim it up towards the liver if you can. One second. There we go, all right. Great. Thank you. I have a high quality MRI preoperatively, and so I am less concerned about other disease, but I always try to do a full ultrasound of the liver. And so... I'm just gonna let that go for the moment. All right, Colin, can we increase the depth of the ultrasound probe, please? The other way. Keep going, keep going, keep going. One more. Yeah, that's great. Thank you. Okay. Can you push that in a little bit, Kelsey? Good. Okay. So there's the main portal vein bifurcation. There's the right going towards the screen right. And then there's the left going up that way. Here we can follow that hepatic vein back. And there's the junction with the IVC right there. And I am just going to take a quick look at the parenchyma. Can you pull back a little bit, Kelsey? A sweep of segment VIII. And VII. We see our gallbladder there. Then we see our primary lesion segment V/VI there. And I don't see any other lesions there. I'm gonna evaluate segment IVb carefully 'cause that's where our LI-RADS 3 lesion is. All right, Colin, if we could hit the cine button, or the clip button, sorry. Okay, that's great. We'll just quickly check the left side of the liver. Can we decrease the depth? Keep going. Good, that's great, thank you. So that's segment III. So we can see the portal vein, left portal vein right there. And then I'm gonna follow it down this way to identify, there's the segment. So, up here is gonna be segment II branches as I head up towards segment II. And then when I come back we can see that branch coming off right there, which is headed to segment III down here. Okay. And then we're gonna use the ultrasound. All right, can you pull that back, Kelsey? That's great. Thank you. Leave it there because I'm gonna use it in just a moment here. All right, bring it back in for me. There we are. That's good. All right, and then can I get the hook cautery in number one, please? Yep, so fenestrated bipolar out, and can I get the hook there, please? Hook coming in one. Okay. Excellent, thank you very much.

CHAPTER 7

So I'm gonna try to mark out the extent of this lesion. I can see that there's a hepatic vein branch coming right there, so there's the hepatic vein coming down right there, and then you can see it bifurcates and branches right there. All right. And we're gonna identify the extent of our mass, put that right in the middle of our probe, and so I know that the mass goes at least this deep. And for liver, I want the monopolar up as high as I can go. So I know that this arrow corresponds to the middle of that ultrasound image that we can see there and I'll put the edge of the tumor right at that arrow, and then I can use that to try to define a margin. So if I stay out here, we should be okay. Try to stay away from the probe here next time. And then radially, again, find the edge extent of that tumor, that edge, put that right in the middle of the probe, and then measure margin. Again. Once I have the margins figured out. Okay. Angle the probe to about here. All right, if you could pull that back a little bit, that'd be great, thank you. So I'm just gonna mark out on the capsule. Are we evacuating smoke as much as we can? We can do that on the 15 port. It might be a good site to do that on. All right, can I get the fenestrated bipolar back in number one, please? And then can I get you to pass in another two-by-two, please? There you go. Thank you. And could you just mark down that we have two two-by-twos in there if you haven't already, which I'm sure you have. Can I get the hook cautery in number three? So ProGrasp out, please. So it seems a little bit deeper on the bottom side than on the top. Okay.

CHAPTER 8

Now, if I started medially, I would lose the ability to put traction on the lateral aspect, and so I'm gonna start laterally out here and develop this plane first, and then we'll come down this way second. All right, so can I get the Harmonic in number one and the fenestrated bipolar in number three, please? So hook out and fenestrated bipolar out. I'm just gonna be cognizant of that bowel that's over there. I've set my bipolar to eight. Okay. And the Harmonic, just like in the open surgery, open liver resection, we're gonna use it by turning it on outside. I think it's tested now, is that right? Yep. Okay, thank you. So I'm gonna turn it on as I advance it. Gonna take small bites to begin with. I'm gonna slowly work the hot bottom blade up through the liver parenchyma. I'm gonna take my time. I'll try to do as much as I can without a Pringle, without applying the Pringle. And you can see how with the Harmonic I lose a degree of freedom because I don't have that wrist articulation, and so I have to be a little bit more cognizant about how I'm retracting so that the angles are appropriate. Let's do the Cadiere in number one, please? All right, can I get the Harmonic back in number one, please? So I could see that there was a little bit of bleeding there and then also I could feel a little bit of, or I could use at least the feedback of the visual... So that's a great visual to see how the Harmonic works, right? As it's coming through that liver tissue. Can I get the ProGrasp in number four, please? And I wanna close the clamp, but I want to kind of lift that hot blade up as I'm doing that and let it work. Can I get the Maryland in number three, please? And can I get it hooked up to energy, please? All right, hot Maryland. Thank you. So if I use a stapler, I'll use the 35 vascular. Kelsey, you think you're gonna be able to clip that? How about an 0 silk to start out with cut to 15 centimeters, and then I'll have you clip it on the stay side. It's gonna be a laparoscopic clip, the metal clips, please. Thank you. All right, come on in with your clip applier. And then I'm gonna try to pull medially and get control, and right there is good, good. Down into the liver a little bit. Right there is perfect, right there. Go ahead and fire. And as you fire, try not to move... Oh, okay. That's all right. Good. Leave that clip there. Good. Turns out it was nothing, which is great. Okay, can I get hot scissors in number three, please? One more clutch. Thank you. I have to remember that hepatic vein is gonna be kind of deeper, but right in this area right here, right? And I draw a circle, but in reality it's gonna be kind of a pyramid. And as I'm pushing the Harmonic into the liver, I'm looking for the liver to move instead of just give way. And if I see it move the parenchyma around where I'm using Harmonic, then I'll know that there's, that that tip is up against the structure of some sort. Okay, I need to apply some pressure. Can you exchange my fenestrated bipolar out, please? Or sorry, my scissors out, please? Yep. I'm gonna apply the Pringle maneuver in just a moment here to try to get control of that. Okay, can I get the Cadiere in number one, please? Can you come in with that suction? I'm gonna apply a Pringle maneuver here. Okay, I'm gonna make sure that the duodenum is outta the... Anesthesia. We're putting the Pringle maneuver on, can you start a timer there, please? Yep. Thank you. Suction here. Uh-huh, come on out. Suction right there. Okay, come on out for a second and suction down below. Yep. Good. Okay, can I get hot scissors, please? In number three? Yep. Uh-huh, can you suction some of that clot out laterally? There we go. Thank you. Can you suction some of that clot out? Are we still dripping? Probably not. Good. Okay. What's that? Sorry. Okay, sounds good. All right, here we go. Get ready to suction here for me. Suction. And show me where that is. All right, let go of that a little bit. Let go of things, come on out with this suction. Good. Suction the bubbles down below. Yeah, exactly. Yep. Do you have... All right, can you get another two-by-two in, please? Good. Uh-huh. All right. Can you suction up here? Right up here, actually. Actually stop for a second. Can I get suction in my number one, please? Have we started a timer? Yeah. Okay, good. Excellent. If you could let me know every five minutes up to 15 minutes, please. Thank you. Okay. The fenestrated bipolar in number three, please. Okay. How much is in that canister, by the way? Okay. 15 right now. Okay, can I get the Cadiere in number one, please? Oh, we're still bleeding here, huh? Can I get the scissors in number three, please? All right, and then, Kelsey, can you come in with suction? I don't think that Pringle is doing as much as I was hoping it would do. Uh-huh. Can you suction up there a little bit more? And really light tension, okay? Come back. Suction right here. Okay, come back a little bit. Come on out for a second. Can you suction in there? Oh, can you hook up that... Oh, sorry, can I get the... Come on out, Kelsey. Can I get the fenestrated bipolar in number one, please? Yeah. All right, thank you. Come on back in with suction, Kelsey. All right, suction right there. Okay, thank you. Mm-hmm. Suction right there. Right up here where the blood is. Right there, Kelsey. Thank you. Mm-hmm. Can I get a new two-by-two in here, please? Can you take this one out? How's he doing with the Pringle maneuver there? Can we take the bipolar out and clean it, and can I get the bipolar back there? Can I get the suction? Yeah, keep going. I'm gonna use the suction for a little bit, and then I can use the Cadiere after that. You gonna take that out? Yeah. Let's take this thing outta here, too. Can I get the Harmonic in number three? How much time do I have left? For full 15 minutes? Okay, if you have the fenestrated bipolar, I'll take that in one. If you don't, I'll have the Cadiere and then the ProGrasp number three, or sorry, any other graspers. Can you set a timer for five minutes, please? That looks still pretty dry. Okay, I'll take the Harmonic in number three. Did he have any hemodynamics changes with the Pringle coming off? Okay, great. Thank you. Five minutes. Thank you. Can I get the Marylands, please? In number three? Yes, please. I have to take off your bipolar then. Okay, that's all right. Can you get a stapler ready, please? 35? 35. White load. Yep. 35 white load, vascular load. Kelsey, you're gonna be able to get that? And very gentle. I wanna be able to pass the angle tip pretty, it should pass pretty easily here, right? And it's gonna be kind of like a fire like that, all right? All right, go ahead and open that and then articulate towards the screen left, please? There we go. All right. And see if you can get that tip underneath that vessel there. But don't push in so much as up. Now hold on one second. Okay. Come on out. Yeah, go ahead and close that and take it out and unarticulate it, and then grab a clip applier. All right, you're gonna go up against the stay side first. There you go. Ready? Yep. Right in there. One second. Yep. Good. And just clip right there. Good. All right. And then one more up against the specimen. Good, go ahead. Good. Can I get the scissors in number three, please? And then come in with suction, Kelsey. Okay. Suction right here for me. Gentle suction right there. Show me what's there, but don't scrape against any of the liver there. Yeah, there you go. Perfect. Just like that. Yep. Suction right... Suction right up here. Okay. Show me what's here. If you can suction right there. Okay, I'll take the Harmonic back. One second. One second. Okay, go ahead. You can take this out. The scissors out, please. Oh, can I get that fenestrated bipolar hooked up again to bipolar energy again, please? Okay, thank you. Can I get the Maryland, please? If you could take the Maryland in number three, if you could switch the bipolar energy. Can you pass in another silk, please? Oh. All right, get ready to come in here with a clip applier. I want you to clip on the stay side of this. Mm-hmm. Just... Sorry, just let me control the other... Just right there. Okay, push in there. There we go. Right there is good. Go ahead and fire. Great. Come on out. And then if you could fire on the other side, that'd be great. A little bit right there. Go ahead. That's good. And then scissors to me in number three, and can you make those hot, please? If you could take that tail out, that'd be great. Thank you. All right, can I get the Harmonic back in number three, please? Thank you. Okay, can I get the Maryland in number three, please? Yeah, if you could make that one hot, the Maryland is, yep, thank you. Thank you. And take another silk. Right there is good. Go ahead and fire right there. Hold on one second. Do we need a new clip applier? Okay, thank you. Uh-huh. Go ahead. Scissors in number three, please. All right, if you wanna grab just this tail here. Leave that other one in, Kelsey. Yep. Good. Perfect. Okay, can I get suction in number three, please? Okay, can I get the Harmonic back, please, in number three? Okay, can I get the Cadiere in number three, please? We're gonna go back on Pringle. If you could start a timer when I let you know? Okay, start the timer now, please? Okay. Harmonic back in number three, please. Okay, can I get the Maryland in number three, please? Thank you. Come in with the clip applier. Excellent. Have to be very controlled, especially on the stay side 'cause the vein is right there. Okay. Okay. Just a little bit less over that side. There we go. Go ahead and push in right there a little bit. Okay, now... Okay, there we go. Perfect. And just right there. Go ahead. There we go. Good. Open up. Stop for a second. You're clamped on a vessel, so push in a little bit. Okay, go ahead and squeeze again all the way. Squeezed all the way. Okay, now open. It's not opening. Okay, stop for a second. Don't move. Can you try to pry the jaws open? Got it. Because this is on, okay, good. All right, let's do another one over here. Can I get a new clip applier, please? Do a new one now. Okay, come on in. Yep, go ahead. Good. Go ahead right there. Great. Scissors in number three, please. Go ahead. Okay, that's fine. I'm gonna ask you to take that out in just a moment. Can you take this out and can I get the Harmonic back in number three, please? Great. Oh, can I get the fenestrated bipolar hooked up again, please? Thank you. Four minutes on the clock. Sorry? Four minutes. Four minutes left? On the timer. Okay, thank you. So with the Pringle maneuver, I'm doing a 15 minute on, five minutes for a break in between Pringle. His liver function is otherwise normal, so he should be able to tolerate it pretty well. And he is otherwise healthy. So we're getting back to that place where we had the bleeding earlier, and what I'm hoping to do is get that bleeder from this side and hopefully not cause it to bleed from this side. The next step is gonna take a little bit of time in terms of that pedicle that I see there, and so I don't want to potentially let the Pringle go for longer than I was expecting it to go. So I'm just gonna take it off. We can restart the timer for five minutes as we're off Pringle now. And just let me know when the five minutes is up. Kelsey, can you come in with a clip? And actually can I get the hot scissors in number three, please? And just fire a clip right here, just on the surface. It doesn't even have to be grabbing anything, just let it fire, right there is good. All right, can I get the Cadiere in number three, please? All right, can you restart the timer for 15 minutes, please? And just let me know every five minutes, please. Thank you. All right, Harmonic back in number three, please. That's good. Thank you. How much time left? Three minutes. Excellent. Okay, we can start another timer for five minutes this time, please. Mm. All right. All right, Kelsey, do you think you can put a clip on there gently? If you turn it... Actually, turn it so its tips are down. And I want one tine going in right here, and one time over here. And just fire a clip and I'll use cautery after that, so don't worry too much about the placement of the clip. Right there is good. Go ahead. That's great. Thank you. Can you suction here, Kelsey? When you suction in liver, it's not like the the pancreas, right? Where you try to suction in the groove. All right, if you could start another 15-minute timer in just a moment. Okay. Go ahead and start another timer, please. Okay. Okay, can I get the Marylands in number three, please? Okay, can I get a silk, please? Thank you. All right, get that stapler ready, Kelsey. Give me a second to develop that space for that stapler. All right, Kelsey, you see that? Yeah. So it'll be just like that, okay? Mm-hmm. Hold on one second, I need a better grip. There we go. Hold on, I need a better grip of this silk here. One second. Ten minutes on the timer. Okay, thank you. All right. All right, now you're gonna hold it right there for a second, okay? And I'm going to do that. Now, lift it up in the air a little bit. There we go. Good. Advance it. Keep going, keep going. Uh-huh, keep going. Okay, there we go. Go ahead and close right there, and go ahead and fire. Firing. Mm-hmm. Okay. Great. Nice job. All right, Harmonic in number three. Thank you. Maryland again, please? Can you have another stapler load ready, please? Okay, thank you. I think we can tie this one and clip it. For the hepatic veins, I'm more comfortable with that than I would be for a portal structure. And most hepatic bleeding I can control with a cautery, especially if I have a clip to weld to on there. Can you go ahead and clip that? Just to the left of that, actually. Yep, it's okay if you put have to put it on that side of the suture. That's okay. Yep, good. Perfect. And then push over to the right, and then go ahead and fire. Perfect. Another one on the specimen side. Uh-huh. That's great. All right, I'll take Harmonic this time. That may be a portal structure. There's a bile duct right above it. Can you put a clip on this, Kelsey? Yep, just push into that little space, right there is good. Go ahead. Fire. Perfect. That's good. How much time is left, sorry? 15 minutes up. That's been 15? Okay, thank you. Five minutes? Not yet, I'm gonna leave the Pringle on just for a moment, 'cause we're just at the end here. Kelsey, you wanna grab that last thing with the stapler? Stapler? Yeah. I'm gonna have you staple in just a moment here. Okay, can I switch the Harmonic to number one, please? We're gonna take one more staple fire. Do you want a bag for that? Yes, the 15 bag, please. Come on in with the Harmonic. All right, come on in with that stapler and see if he can get this last bit here, okay? Watch that clip. So just advance, I'm gonna try to lift it up here for you. There you go. Drop your hands a little bit, or drop your... Yep, good. Perfect, right there is good. Push in. Push in, push in, push in. Push in a little more. There we go. Go ahead and fire right, or close right there and see how it closes. All right, now push into the liver a little bit, and then go ahead and fire. Excellent. Okay. We're gonna come off of the Pringle here. Okay.

CHAPTER 9

Can you pass some Surgicel in, please? A big piece of Surgicel, please? Excellent, thank you. Okay, another... Yep, thank you, go ahead. And another dry Ray-Tec passed in, please? Thank you. Okay, can I get the fenestrated bipolar back in number one, please? You want scissors in three? No, a hook cautery please. I prefer the hook cautery for gallbladders if I can use it. If it's just a straightforward gallbladder that I'm trying to reduce number of instruments, then I will use the scissors. But in this case, we already have the hookup, so I prefer that.

CHAPTER 10

So I try to grab across the cap of the gallbladder when I'm doing these. And then retract that as far as I can towards the left shoulder without... Or the right shoulder, sorry. All right, Kelsey, let me know when you're there. Okay, they're all yours, so go ahead and grab the infundibulum and incise the peritoneum. So I think the peritoneum has already been started right about here. So if you wanna put your hook in and go up over the cystic artery that way. And retract with your left hand towards the left. There we go. Mm-hmm. Great. And keep going over to the gallbladder, so one of the... Yep, one of the tricks I used to retract, sorry, I took the instruments. One of the tricks I used to retract the gallbladder is, if you wanna see this side of it, put this tine into the gallbladder and then grab and then go do that. And then if you wanna see the other side, same thing except just do that, all right? Okay, and... So they're all yours. I imagine that the cystic artery is gonna be right here somewhere, and so I'd ask you to go up the peritoneum here and then up that way. Yeah, exactly. Good. Yeah, that's either gonna be... That's probably gonna be cystic artery right there. Yep. Mm-hmm. Oh, be careful, the tension there. That's all right. Keep going. There you go. So bring your left hand closer. Yeah, exactly. Yep. Just for that one bite. It's likely just been... There you go. Mm-hmm. Let me show you another trick. So what's happening is that you're kind of turning your hook this way and then you're having to put a lot of tension, right? Instead, just a little bit more aggressive. So you turn the tips away from the tissue, the tip will pop through and then you can... So when you take a bite up here, turn the tip so that the tip goes through, and then you see how the tension becomes more effective, right? Okay. They're all yours. Mm-hmm. And just go... Yes, exactly. Good. Now tap, tap and side to side. There you go. Now go through it. Nice. Good. Tap, tap. Side to side. Nice. Good. Good. Great. What are you gonna do next? Probably gonna unzip up the other side. Sounds good. Now one of the benefits of the robot is that you can get your elbow... Yes. Nice move. Yep, exactly. Yep, good. Mm-hmm. The liver resection... So tap, tap, side to side. Nice. The liver resection portion of this case is done, so you can give him as much fluid as you need. Who's up at anesthesia with me? Colin, are you here? Danielle? Danielle is not here. Okay. Hey. How's he? That's all right. How's he doing? Okay, you can give as much fluid as you'd like now. The liver resection part is done. Awesome. So, yep, thank you. So, let me see this for a second. So, this clearly looks like cystic artery, right? And then look at that right there, right? Branch to the hepatic... Branch to the liver, so we gotta drop that. Nice, that's a great example of how if you stay too close to the liver, then you can get underneath that. That looks great. All right. They're all yours. What are you gonna do next? Next, we're going to dissect these out. Okay. There's a little ledge right there. And if you go up... Yeah, exactly. Perfect. Mm-hmm. So I would insinuate your hook right in here. And go up along the side of the cystic artery. Yep, exactly. Yeah, that's good. So if you look down here... Yep, exactly. And there seems to be some kind of... Yeah, crossing. Crossing here. There might be aberrant anatomy of the artery, but we can stay right up here and drop this little thing right down. Or you can take it, it's up to you. It's just a little... I think it's a little arterial branch, right? Yeah, I think so. Mm-hmm. Nice. Your left hand should come outta the port a little more. Yeah, there you go. Nice Uh-huh. Yeah, exactly. I would regrab that infundibulum, see if you can lift that up a little bit. There we go. Nice. Mm-hmm. Yep. I don't think we really need to work towards... Yeah, keep going. That's good. You know, I think we can work up onto Infundibulum, right? And you skeletonize that cystic artery. Yeah, yeah, go ahead and skeletonize that. Yeah. Perfect. Good. Yep. Nice. Nice. Yeah, your instinct was right, I want you to get that infundibulum off. So I want you to dissect up the infundibulum right here. Yeah, exactly. Yep. Yep. Right, so what are the three components- I know we've talked about it before, but three components, of the critical view of safety? Two and only two structures entering the gallbladder, dissect a third off the cystic plate. See the liver behind us. Yeah, so the seeing the liver part is really about dissecting the bottom-third of the gallbladder off of the liver, right? That ensures that this duct here isn't coming up like this and then diving back down, right? And so I just want you to dissect back here this stuff back on the back of the liver, or sorry, back of the gallbladder. You can do that. Yep, that works. Nice. Yep, go to the front. As long as you can see through it. Good, now the other components of the view of safety. So let me take over for a second. So critical view of safety, three components: Dissection of the hepatocystic triangle, dissection of the gallbladder, the bottom-one-third of the gallbladder off of the liver, off the cystic plate here, and then two and only two structures going to the gallbladder. I would say this is pretty good. I would say I'd probably work on getting more over here. There. Yeah. And so I'll have you do that. And then the other components of safety, so there's Rouviere's sulcus, right? So Rouviere's sulcus, and then the base of segment IVb. And the way to really identify the base of segment IVb is that you see that there's a peritoneal reflection coming here to the gallbladder, to the cystic plate, and then a peritoneal reflection to the hepatic hilum. And where that crosses, where those two lines cross or form a corner, it's from there to Rouviere's sulcus that if you draw a line you should try to stay above. And so we've definitely stayed above that, right? So I'll have you just kind of clear off a little more back here, and then we can start talking about clipping. All right. They're all yours. Yeah. Nice. Nice. That's great. So, do that again. Yeah. And then flip your hook around and get that, or what I want you to... Yeah, hook that stuff that's back there. Yeah, there you go. Perfect. Nice. Good. All right. If you're satisfied... I am satisfied. Okay. Let's go ahead and clip. Can I have a clip in three, please? Clip in three? Yep. Coming in. Nice. Looks good. Excellent. I'll take another, please. Feel like you don't wanna... Yep. Exactly. That's great. A lot of the residents will sometimes have trouble getting that clip off of the backside, right? And you do the correct thing where you're trying to make sure that the clip applier, right, when you're releasing it, instead of just opening it you kind of have to turn your wrist up that way, right? So you change the angle from like that to like that and it'll come off of that backside. We can come in with the clip whenever you're ready. Yep, sorry that took me a moment. That's all right. Okay. Coming in. Push your left hand in and up. There you go. You see how that opens that up a little better? All right, go ahead. Nice. I would say put the clips on the cystic artery right away as well. Perfect. Okay. Another clip. Coming out. Mm-hmm. Little higher. There you go. That's good. Mm-hmm. Okay, I'll take another. Okay, coming out. We're gonna take hot scissors next. Hot scissors in number three, please. Okay. Coming out. Mm-hmm. Coming in. Do I take this first to here? Mm-hmm. Yeah. And no burning on this one, right? Okay. Nicely done. Do you like taking it off the with the hook or with these? Up to you. Well I already got these. Okay. Just watch that artery, right? Yeah. What I would suggest is start a little lower and put your instrument... Or no, no, right where that defect is, right? And then, yep, and then slide it up. And I think that these are gonna be very thin vessels you can take with the scissors. And we'll find out, won't we? Good. Oh, or I'm gonna get into the gallbladder. Mm-hmm. Yeah. That's fun. The only reason I want you to minimize that contamination is because I want to make sure that we can evaluate that liver bed for a bile leak, okay? But just keep going, doing what you're doing. That's all right. Mm-hmm. Once you get it freed up, then you can grab it in a way that minimizes the leakage of bile. Great. Now one thing I'll show you, one second, is you can use your elbow, and I might actually cause a little bit of bile leaking while I'm trying to do this, but if you turn instrument that way, you can use your elbow to retract the remainder of the gallbladder, okay? And keep it outta your way. Okay. They're all yours again. Now, you want your left hand to be coming outta the port here 'cause you want it to be pulling away from the liver. There you go. Uh-huh. So zoom out a little bit. Oh, there goes is the bile. All right. Okay, well, that plan failed. Okay, can I get suction in number three, please? Coming out. Suction in number three, please? Go ahead, take scissors, please. I can't tell if that's gonna be... Yep, thank you. Let me just wash that liver bed and we'll be all right. I think this was all bile that came down from the gallbladder. Yeah, I think so too. But we'll find out. Okay, let's get the scissors back in number three, please. Okay, it's all yours again, Kelsey. You may wanna let go with with number four. One thing that I usually do with that is either hold the liver back or grab the falciform and retract that. But you can do that as well, that's fine. Oh, it's just like a bag of nothing. Uh-huh. Okay. Switch over to your scissors and then pull that outta the port. You can still put tension on it, right? So go ahead. Can I just show you a little bit better retraction here? Just grab it like that so that you get a little more. Okay there, it's all yours. I think you're still controlling four. Yep. Okay, good. All right, go ahead. There you go. So you're gonna need a little more tension and... Yeah, exactly. There you go. It's all right. Mm-hmm. Good. That's nice.

CHAPTER 11

Okay, if you could put that over by the specimen. And if you could scrub back in, Kelsey, that'd be great. And then if you could have a 15 bag ready, please. Let me give you this stuff back. So that's the Surgicel here and the Ray-Tec here. That may be a little too thick. Let me know. Sorry. Okay, good. And then if I could get the ProGrasp in number three, please? Okay, and then go ahead and insert the bag. That'll be easy. Hold on one second. Let me lift this specimen up and out. Lift it up towards the ceiling. Go ahead and close that and bring that bag into the pelvis. And then can I get the ultrasound probe passed in? Hold on one second. There we go. Good.

CHAPTER 12

Okay, can you reduce the depth on that ultrasound, please? Keep going. That's good there, thank you. That wouldn't be it. Huh. All right, so that LI-RADS 3 lesion should be about here. Somewhere... I think that's probably what it is right there. You can see that vessel right there is, and that's a hepatic venous branch I think. And so this right... There. Looks almost like a cyst. You see that anechoic structure? Okay. So it just goes out. Ends right about there. That'll be big enough. Okay, can you take that ultrasound probe out? Okay, can I get Harmonic in number three, please? Thank you.

CHAPTER 13

I'm gonna need a separate extraction for this, Colin. Smallest one we have. Okay.

CHAPTER 14

Yeah, whenever you have the bag, I'm ready for it. You can take that one outta the 15 port, I bet. Can I get the scissors in number three, please? Can we reduce the pneumoperitoneum to eight millimeters of mercury, please? So we can assess for any bleeding. What do you wanna call the specimen the pull out? Excisional biopsy of segment IVb lesion. I'm gonna turn that cautery out to eight. And I will leave that Pringle in place in case I need it until I'm all the way down, all right? That one is gonna be sent to permanent only. Can I get suction in number one, please? Can you put some pressure on that bag for me, please? In just a moment, it'll take a second before we're ready for you. Actually it looks pretty good right now, Colin. We'll be all right. Okay, can you pass in another Ray-Tec, please? Can we get another dry Ray-Tec and then some Floseal, please? Go ahead and grab the other one then. Perfect. Thank you. All right, can you take that scissors out, please? Yes, please. Can I get the fenestrated bipolar in there, please? And go ahead and take this Ray-Tec out. Actually, Kelsey, pass in another dry white Ray-Tec, please. Thank you. That'll be our last bile leak check here. No, just Floseal will be all right. Okay, let's just check this real quick. And so I'm rolling it away, I'm looking for bile staining on that, and I see a little bit of red, which is expected, but nothing obvious for a bile leak, agreed? Agreed. All right. Can we go back up to 12 on that pressure? Or sorry, back up to 15 for that pressure, please? Been set back to 15. Thank you. All right, and whenever you're ready with the Floseal, I'd like you to come in with that. Can I get a Cadiere in number one, please? And there should be none left in the abdomen, correct? That's right. All right, and then let's get one more dry Ray-Tec in... Or sorry, wet Ray-Tec in, and then the Floseal in, please? And then, Kelsey, I want you to paint that, right? The Floseal. I want you to try to apply a little bit to that extra-excisional site as well. All right. Uh-huh. Ready? Yep. Go ahead. So one syringe will fill that, and then you have the pusher, right? We'll likely need two, Colin, sorry. And start over there. And kind of move across. Good. Stop. And come down this kind of crevice right here. Good. Is that all of it? Yeah. Okay. We've got more if you want. Yeah, that'd be great. Can you reconnect that? Okay, it just got knocked off 'cause of... Yep. Let me know when you're ready for the last little bit in here. I want to get the part that was the most red. There we go. Okay, start up here. Mm-hmm. I think this one is a little bit too liquidy. I think we need to mix that a little bit more. Is that all of it? Yes. All right. Good. Thank you. All right, can you do the TAP blocks next? Okay. Do you wanna save some for the close sites? Yes, please. How much does she weigh? What's her med dosing weight? She weighs 83 kilos. Okay, and how much local did we give? I have 80 left Okay, great, we'll do 35 on each side, and then save 10 for the Pfannenstiel, please. Right there is perfect. Go ahead. Nice. Okay. Just do 30 and 30, and we'll save 20 for the bottom, how's that? That's great, you can see the transversus muscles splitting, it means we're in the correct plane, all right? Good. We're gonna go over to the other side. Nice. Okay. Excellent. No drains. Can you take this last Ray-Tec? Let's just check. Looks good. No bile and very little blood, right? Looks good. All right. Both instruments can come out. I'm gonna scrub in. Let me turn all the lights on. We're gonna need an Army-Navy. I'll need for closure 2-0 Vicryl and 0 PDS times two. All right, if I can ask you to move the Mayo stand back a little bit. Can we go slightly reverse Trendelenburg again, please? That's good there. Thank you. So the easiest way to switch that is to open both 'cause the AirSeal can handle that, right? And I shut it off anyways, but that's right. Oh, that's right. So I just do this. Never mind. Yeah. Another Kelly clamp, please? Now usually I would make a Pfannenstiel, transverse Pfannenstiel, but might as well use this, right? Cautery. And Army-Navy times two, please? Looks good. So we're just using the patient's previous... Oh, can we get the cautery down to 3.3, please? So we're just going to go down through the patient's previous laparotomy for his colon resection. All right. Okay. All right. If you could hold that. All right, can I get another Kelly clamp, please? Thank you. I'm just gonna do it right here. If you can lift up on that slightly? Good. Okay. Do you have an S-shape? Slide that in. If you can hold that for me. Army-Navy back, please. Thank you. Let me slide that more over towards the middle. There we go. Okay. So let's see if we can get that out there. I need to expand it up a little bit. So the problem with these livers is that they're more susceptible to... To problems with the margins than others because as they come outta these small incisions, they'll fracture. So as opposed to other specimen, I'll make the incision slightly larger for these. Okay. I think I need more down at the bottom here. All right. Okay. Excellent. What would you like to call it? All right, so one of the specimen in there is the gallbladder, and the other is gonna be non-anatomic segment V/VI resection. Hold on one second, I'll just mark on the label. Okay.

CHAPTER 15

Okay. DeBakey. Okay. Hold on one second, right there. Can we get 0 PDS? We're not gonna use those Vicryls. We're not gonna close the peritoneum here. All right, can we level the patient out again? We can take these ports out. So I always try to evacuate as much air as I can. All right, Army-Navys and then 0 PDS to Dr. Fletcher, please? Hold on a second. Can you dry that up and take a look at one? Can I get this back for a second, please? Yeah. Can I get a DeBakey? Uh-huh. Yeah. I think there's... Okay, one moment. Can you hold these for me? I don't like how, what that's looking in the back. Can I get that 2-0 Vicryl, please? I'll grab this DeBakey from you. And pull on this right here. 2-0 Vicryl. Thank you. Can I get the... All right, I'm gonna have you come in here right there. Scissors. Hold on a second. Okay. Now, this is really an unnecessary closure, right? But... Sometimes the edges of the peritoneum can bleed, and so that's the only reason I... Okay, go ahead. Needle down there. I'm gonna grab that from you, Paige. Okay, can we get that PDS back to Dr. Fletcher? All right. Excellent. Mayo scissors. Excellent. Thank you. Surgical oncology? That'd be great. Can I get that other PDS, please? Thank you. Okay. I'm violating my own rule, Kelsey. Of small lengths? Of not grabbing that needle with the... I don't like the idea... Yep, go ahead. I don't like the idea of tying a knot at the apex of an incision, and that's why I will always do two. This patient... Mm-hmm. I'm sorry? All right, thank you. All right. Can I have an Adson, please? A little bit in every one of those incisions will be good. NPO, keep the Foley for tonight. Foley catheter can come out first thing in the morning. No labs tonight, just in the morning. Oh, and can you inject a little bit of this local around that incision, Kelsey? And DVT prophylaxis can start tomorrow morning. Yeah, just 4-0 Monocryl and Dermabond would be great.

CHAPTER 16

So I think the key to minimally invasive liver surgery is patient selection, and this patient had a tumor in a location that was very favorable for a minimally invasive approach. The case went as planned. There was also a point in the case where we encountered some bleeding, but we were able to gain control of that bleeding and were able to complete the case robotically. In many cases, when we do have bleeding as we encountered in the case, sometimes we're able to temporize the bleeding and then convert to open, but in this case we were able to stop the bleeding and continue robotically. I think this is a case that has anatomy that is very amenable to a minimally invasive approach. And the robotic approach in particular allows for a very dry parenchymal transection plane. So I think it's very important to understand how to convert robotic cases to open cases. In our practice here at Penn State, we try to create scenarios that allow us to convert in the most controlled fashion possible. We have not had a case that we've had to convert to an open procedure in an emergent fashion. Even if we do encounter bleeding, especially during our advanced hepatobiliary cases, we were able to gain control of those bleeding vessels robotically at least to temporize those to allow for elective or semi-elective conversion to an open procedure. The most important thing is to plan for it. And so at the beginning of the case, I'll always mark out my open incision should that be required. And I always have someone who is a backup. In case we do encounter bleeding, I always have one of my partners available so that we can convert quickly if necessary. The main components of conversion from robotic to open is to first gain control of the bleeding robotically and in a fashion that allows you to remove the robotic arms and undock the robot so that you can convert to an open procedure quickly, but with control of the bleeding. The placement of the 16-French Foley catheter, the principles are really to place that Foley into the foramen of Winslow and then look for it under the caudate lobe through the lesser sac, through the pars flaccida. This patient had a very favorable anatomy in that the foramen of Winslow was widely open and the pars flaccida was easy to open up. In many cirrhotic patients, sometimes the foramen of Winslow can be obliterated, and so it can be difficult to achieve that. Sometimes a very harrowing part of the case is to try to obtain access to the lesser sac through the foramen of Winslow to pass something to allow you to do a Pringle maneuver. But you'll see that the passage of that Foley catheter through that foramen of Winslow was quite smooth and we were able to obtain that fairly expeditiously. So the port placement for this case allowed for parenchymal transection in two planes and both of those planes were pointed towards my number three and number one robotic arms, and that's kind of the way I had planned it, is so that my Harmonic, which doesn't have that wrist articulation, would be able to work basically in one plane and I would be able to manipulate the liver with either the ligamentum teres or the gallbladder in order to make that plane point towards either arm three or arm one. At one point during the case, I had started the lateral parenchymal transection, and there was a point at which my harmonic scalpel had gone through a vascular structure along the lateral parenchymal transection plane, and you can see some of the techniques I tried to use to control the bleeding. In particular, the first thing is to try to tamponade the bleeding. And so I tried to grasp the liver on the right side of that patient and push that into the parenchymal transection plane along the lateral aspect of the tumor. And some other techniques that can be used are to first of all apply that pressure and then to apply the Pringle maneuver, which you can see that we attempted. And then finally is to place either Surgicel or a Ray-Tec into the parenchymal transection plane and just tamponade that bleeding. And once I gained control of that bleeding, I elected to move to the other side. So that's an important aspect of liver resection, is that if you have... Or any surgery really, is if you get into some bleeding in one particular location and you're able to control it, then it might be a good idea to work in another spot. And in that setting, we were actually able to come around and use the parenchymal transection from the medial aspect of the tumor to actually gain control of the bleeding vessel that allowed us to complete the parenchymal transection on the lateral aspect. Another key component to the parenchymal transection is to ensure adequate margins. And you'll notice that I use ultrasound to demarcate my margins, using the arrow and the measurements on the ultrasound probe to measure out my margins, and then I'll also try to check my margins as I'm proceeding with the parenchymal transection. Postoperatively, these patients will be progressed fairly quickly clinically. The robotic approach allows us to do these operations with minimal pain. Usually, we will use a Pfannenstiel incision for extraction. In this case, the patient had a previous midline incision and so we used his previous midline incision. The Pfannenstiel incision in particular is very well tolerated and it has decreased rate of complications in terms of hernias, but also decreased pain. And we also use TAP blocks at the end of our case. So that reduces narcotic use in these patients, and most patients will spend about one or two nights in the hospital before they're able to go home.