Surgical robot can help safely remove the caudate lobe

Resection of tumors in the caudate lobe (a deep, hard-to-reach part of the liver) is recognized as one of the most technically challenging procedures in hepatic surgery due to its unique anatomical position and complex vascular relationships.

Researchers at Boston University Chobanian & Avedisian School of Medicine now show that it is possible to remove the caudate lobe safely using a surgical robot, even in an older patient, and still remove the cancer completely. The clinical case they describe in the journal Annals of Surgical Oncology, combines two "guidance" tools (1) a hanging/traction technique using the Arantius ligament and (2) Indocyanine green (ICG) "negative staining" to clearly mark the caudate lobe boundaries and guide a margin-focused cancer operation in a very difficult area.

"The caudate lobe is one of the most technically demanding areas of the liver-it's deep and surrounded by critical vessels," said corresponding author Eduardo Vega, MD, assistant professor of surgery. "Robotic surgery can help us remove select tumors through smaller incisions, with less pain and blood loss and quicker recovery, while still aiming for cure."

The researchers describe step-by-step a surgical technique they used to treat a 79-year-old patient who had rectal cancer and liver metastasis in the caudate region. They began by using an intraoperative ultrasound to find the tumor and map nearby important blood vessels. Using a surgical robot, they then used a hanging maneuver with the Arantius ligament to open a safe working space near major vessels. Next, they temporarily blocked the small portal branch feeding the caudate lobe and injected a small dose of ICG dye (2.5 mg). Under the near‑infrared camera, the remainder of the liver lit up while the caudate lobe stayed dark, which allowed the surgeons to see the borders clearly and protecting critical structures while removing the caudate lobe.

After the liver procedure, the primary tumor (superior rectal cancer) was resected robotically. This enabled definitive cancer resection entirely via a minimally invasive robotic approach, and the patient completed subsequent treatment without complications.

"Our goal is to make complex liver tumor surgery safer and less invasive, so more patients can recover faster and still receive a curative operation. By combining robotic precision with ultrasound and fluorescence guidance, we hope to expand access to high-quality cancer surgery-even for tumors in the hardest-to-reach areas of the liver," adds Vega, who also is a hepato-bilio-pancreatic surgeon at Boston Medical Center.