Our standard port placements for right-sided liver resection are shown in Fig. 1. The placement of the camera provides adequate visualization of the right side of the liver hilum. The third arm is used for retraction and placed as a right-handed instrument. Two laparoscopic assistant ports are placed in the lower abdomen and the specimen is usually extracted via a Pfannenstiel incision. The location of the camera port is generally in line with the transection plane.

(1) Harmonic scalpel (nonarticulating robotic instrument). (2) Camera. (3) Maryland bipolar forceps (with electrocautery). (4) Cadiere forceps.

We utilize the rubber band retraction technique to provide steady exposure of the parenchymal transection plane without having to use any robotic or laparoscopic arms for this task [1,6]. One end of each rubber band is anchored with stay sutures at the liver edges of the right and left resection margins. Each rubber band is then externalized on the corresponding side of the abdominal wall and secured with a clamp to the drapes (Fig. 2).

The third arm is used to gently lift the inferior surface of the liver off the hilum. Parenchymal transection is performed with a Harmonic scalpel and Maryland bipolar forceps [1–6] (Fig. 3). The caudate lobe had been previously divided during the mobilization of the right lobe. Small intervening vessels and oozing from the parenchyma are controlled with bipolar electrocautery. As more of the parenchyma is transected, the liver edges are continually retracted due to the elasticity of the rubber bands.

Segment 5 and 8 draining veins are carefully dissected with Maryland bipolar forceps and divided between Hem-o-lock clips (Fig. 4). Smaller branches are ligated with small metal clips. When the majority of the parenchyma has been transected (leaving 1–2 cm of liver anterior to the inferior vena cava [IVC]), we divide the RHD.

All the parenchyma on a plane anterior to the hepatic duct is divided, exposing most of the circumference of the duct. ICG dye had been previously injected intravenously during hilar dissection, and fluorescence should be visualized in the bile ducts at this stage. Firefly is used to identify the bile duct bifurcation and the RHD (Fig. 5). The location of RHD division is chosen based on the surgeon’s interpretation of the cholangiogram. There are two ways to transect this duct: (1) clip-and-cut; using the Maryland forceps, umbilical tape is circled around the entire hepatic duct with its surrounding hilar plate tissue. A large Hem-o-lock clip is then placed in the distal RHD, ensuring that it does not encroach onto the bifurcation. The proximal RHD on the graft side is then sharply divided (Fig. 6). The stump of the distal RHD on the donor side is suture-ligated with running 5-0 polydioxanone. (2) Cut-and-clip; the RHD is cut at the chosen point without cutting the hilar tissues that are posterior to the duct (there is usually a vessel in this tissue). This hilar plate tissue is divided between two small metal clips. The stump of the distal RHD is suture-ligated with running 5-0 polydioxanone.

The choice of technique is influenced by the length of the RHD, as the Hem-o-lock in the clip-and-cut option tends to take up an additional 0.5–1 mm of RHD length, and the ease of encircling the RHD with its hilar plate tissue. The cut-and-clip option may lead to fewer bile duct openings for recipient anastomosis [7].

Once the RHD is transected, the laparoscopic assistant inserts a grasper or suction catheter into the space previously created between the posterior liver and retrohepatic IVC. This grasper is used to lift the liver off of the IVC to facilitate transection of the remaining 1–2 cm of parenchyma, starting at the hilum and progressing in a cephalad direction [1-3]. Eventually, the grasper is inserted into the space between the right and middle hepatic vein and the final portion of the parenchymal transection is completed (Fig. 7).