Surgical technique for fully robotic two-stage hepatectomy using indocyanine green fluorescence imaging for bilobar colorectal liver metastases.

Surgical resection remains the most effective treatment for colorectal liver metastases (CRLM). In recent years, the feasibility of liver resection for extensive CRLM expanded due to two-stage hepatectomy techniques. In experienced hands, these complex operations can be performed using minimally invasive techniques, such as robotics, and facilitated by image-guided surgery using indocyanine green (ICG) fluorescence imaging. The objective of this report is to present the surgical technique of a fully robotic two-stage hepatectomy using ICG fluorescence imaging. We present a patient with extensive, bilobar CRLM, eligible for local surgical treatment following induction systemic chemotherapy. Both the first and second stage procedures were performed robotically using ICG-fluorescence imaging for resection margin guidance. The key steps, of both procedures, are outlined in step-by-step surgical technique descriptions detailing patient positioning, trocar placement, instrument use, Pringle maneuver, and parenchymal transection technique. Tips and tricks, critical to performing the procedures safely and successfully, include careful patient selection to match surgeon skill and experience as well as use of ICG and intraoperative ultrasound for intraoperative guidance. The patient recovered from both surgeries quickly without major complications. This report shows that robotic ICG fluorescence-guided two-stage hepatectomy seems to be a safe and feasible procedure for treatment of bilobar CRLM.