Devices for minimally invasive liver parenchyma transection: the SICE (Italian Society of Endoscopic Surgery) Italian and International survey

Backgrounds: Minimally Invasive Liver Surgery (MILS), encompassing laparoscopic (L-MILS) and robotic (R-MILS) approaches, has revolutionized liver surgery, offering reduced morbidity, shorter hospital stays, and improved outcomes while maintaining oncological efficacy. Despite the widespread use of L-MILS, parenchyma liver transection techniques and devices remain debated. This study investigates the adoption of transection devices (TDs) in MILS among 86 hospitals, focusing on surgical practices, device utilization, and outcomes. Methods: The Italian Society of Endoscopic Surgery (SICE) endorsed a cross-sectional internet-based survey targeting general and Hepato-Pancreato-Biliary surgeons. Results: Responses from 86 centers revealed that 77% of institutions is available a robotic platform, with an adoption rate of 87.50% in high-volume centers. L-MILS remains the predominant technique for liver resections, also in case of major hepatectomies, although R-MILS is increasingly utilized. For minor L-MILS, more than 50% of respondents use ultrasonic shears and electrosurgical pencil and advanced bipolar devices, while about 40% of surgeons adopt Cavitronic Ultrasonic Surgical Aspirator (CUSA) in major resections. R-MILS procedures predominantly used Maryland bipolar forceps and vessel sealers, with hybrid techniques (30%) integrating laparoscopic devices (e.g., CUSA) to address robotic device limitations. Conclusion: The minimally invasive approach to liver parenchymal transection is a key component of this surgical procedure. For major hepatectomies, the CUSA device remains the most effective tool, whereas ultrasonic shears, electrosurgical pencil, and advanced bipolar devices are more suited for minor resections. Despite limited access to specialized instruments, R-MILS achieves favorable outcomes in liver transection by employing the crash-clamp technique or hybrid strategies.