Multidirectional Pulley Maneuver Technique in Robotic Hepatectomy.

Abstract

In robotic hepatectomy, two free robotic arms and a non-robotic traction of the liver is crucial for controlling bleeding¹. Recently, a non-robotic arm traction technique with a pulley mechanism were reported². Despite its advantages, this technique has three limits: fixed traction direction, unadjustable force reduction, and limited to one or two uses³. To overcome these limitations, we developed the multidirectional Pulley maneuver (MDPM), which we describe in this study. Between October 2024 and November 2024, five patients underwent robotic hepatectomy using the MDPM. In this technique, a rubber band with a thread is first sutured to the liver. The thread is then passed through the needle hole of the Silicone Ring with Needle (Aesculap Inc) and anchored to the peritoneum or diaphragm. Finally, the thread is pulled outside the body to adjust the tension and direction. To minimize tissue/organ injury, deep hooking and excessive tension should be avoided. The MDPM technique was successfully applied in five cases. In case 1, two rubber bands and two pulleys were used for a robotic central bisectionectomy. For robotic limited liver resections, case 2 used one rubber band and one pulley; cases 3 and 4 used two rubber bands and two pulleys; and case 5 used three rubber bands and one pulley. Median blood loss was 150 mL, and no postoperative complications related to the technique were observed. The new MDPM method provides appropriate tension for liver transection, ensuring a more controlled and comfortable liver resection.