This operative video demonstrates a robotic left hepatectomy performed for a solitary liver metastasis from clear cell renal cell carcinoma.

The patient is an 83-year-old man with a history of Stage IV (pT4 pN0) grade 2 clear cell renal cell carcinoma treated with margin-negative left radical nephrectomy in 2016 without adjuvant therapy.

Surveillance imaging initially identified a 1.3 cm hypodense lesion in the left lateral segment of the liver, which was initially interpreted as likely benign. Over time, serial imaging demonstrated progressive enlargement to approximately 6.6–6.8 cm, raising concern for metastatic disease.

Subsequent diagnostic evaluation included:

• MRI abdomen demonstrating a 6.6 cm left hepatic mass

• PET/CT without hypermetabolic activity but persistent suspicion for malignancy

• Endoscopic ultrasound with fine-needle aspiration, confirming metastatic clear cell renal cell carcinoma

Staging evaluation demonstrated no additional sites of metastatic disease, and the patient was referred for surgical management.

The patient underwent robotic staging laparoscopy followed by robotic partial left hepatectomy.

Intraoperative hepatic ultrasound confirmed a solitary lesion in the left lobe with no additional tumors identified in the liver.

A Glissonian approach to the left hepatic pedicle was performed. Hepatomies were created adjacent to the pedicle, allowing passage of a vessel loop behind the left hepatic pedicle in a Glissonian fashion. After confirming preserved perfusion to the right liver using Doppler ultrasound, the left hepatic pedicle was divided using a robotic vascular stapler.

Indocyanine green (ICG) angiography was used to confirm vascular demarcation of the left hepatic lobe, and the line of transection was marked.

Hepatic parenchymal transection was then performed using energy devices and bipolar dissection with selective ligation of vascular and biliary structures. The left hepatic vein was divided using a robotic vascular stapler, and the specimen was removed in an EndoCatch bag.

The resection bed was inspected and demonstrated excellent hemostasis without bile leak. A surgical drain was placed along the transection line.

The patient recovered well and was discharged home on postoperative day three.

Final pathology demonstrated:

• Metastatic clear cell renal cell carcinoma

• Tumor size 5.7 cm

• Nuclear grade 2

• Negative surgical margins

This case illustrates the use of robotic minimally invasive techniques for anatomic liver resection, integrating intraoperative ultrasound, Glissonian inflow control, and fluorescence imaging to facilitate precise hepatobiliary surgery.