Robotic liver parenchymal transection techniques: a comprehensive overview and classification.

Robotic liver surgery is experiencing a period of great development, but some hurdles still need to be overcome. Parenchymal transection remains one of the most technically challenging steps. The lack of dedicated instruments and the flourishing of several techniques didn't allow surgeons to reach a standard technique so far. The aim of the present paper is to provide an overview of the different robotic liver transection techniques described to date, highlighting the strengths and weaknesses of each one. We conducted an extensive search on PubMed, Scopus and Web of Science, inserting the following keywords: "robotic liver transection, robotic hepatic transection" and focusing particularly on technical reports and paper regarding new surgical methods. This search resulted in a total of 13 different surgical techniques. All the methods described can be classified into two categories the "hybrid techniques" and the "fully robotic techniques" which are based, respectively, on the combined use of laparoscopic and robotic instrumentation or exclusively robotic devices. Another fundamental difference is the division between "one-surgeon" and "two-surgeon techniques", which depends on the level of expertise required of the assistant surgeon at the operating table. This is the first comprehensive review on this topic. Although the existing literature does not allow one technique to be established as superior to the others, the adoption of a standardized method of robotic hepatic transection is highly desirable to optimize surgical results and to allow better comparability of outcomes within the scientific community.