# Devices for minimally invasive liver parenchyma transection: the SICE (Italian Society of Endoscopic Surgery) Italian and International survey **Authors:** Graziano Ceccarelli, Pasquale Avella, Edoardo Maria Muttillo, Maria Conticchio, Giovanni Domenico Tebala, Gaetano Piccolo, Lucia Romano, Riccardo Memeo, Aldo Rocca, Davide Giovanni Grego, Davide Giovanni Grego, Roberto Lauro, Nicolas Pontarolo, Jacopo Andreuccetti, Rossella D’Alessio, Giusto Pignata, Giuseppe Calaciura, Nicola Cinardi, Riccardo Schillaci, Alessandro Mazzotta, Roberta Angelico, Luigi Eduardo Conte, Tommaso Maria Manzia, Marco Anania, Nicola Mancini, Marco Pazzona, Giuseppe Frazzetta, Antonio Picciurro, Annarita Libia, Marcello G. Spampinato, Cosimo Saviello, Giovanni Spiezio, Emanuele Pontecorvi, Vania Silvestri, Teresa Perra, Alberto Porcu, Alberto Oldani, Stefano Olmi, Alessandra Brescacin, Giampaolo Formisano, Matteo Barabino, Gaetano Piccolo, Andrea Barberis, Giovanni Tebala, Andrea Coratti, Giuseppe Giuliani, Francesco Guerra, Andrea Morini, Massimiliano Fabozzi, Maurizio Zizzo, Bruno Nardo, Daniele Paglione, Francesco Pata, Alexander Julianov, Azize Saroglu, Mattia Garancini, Fabrizio Romano, Mauro Alessandro Scotti, Andrea Quazzico, Stefano D’Ugo, Annarita Libia, Marcello Spampinato, Fabio Giannone, Fabrizio Panaro, Federico Sangiuolo, Giulia Lauteri, Federico Maggi, Luigi Masoni, Marcella Arru, Matteo Viti, Belkacem Acidi, Sang Thanh Nguyen, Michele Ammendola, Francesca Vescio, Tommaso Fontana, Flavio Milana, Fabio Procopio, Guido Torzilli, Giulio Argenio, Giorgio Ammerata, Giuseppe Currò, Giuseppe Sena, Curci Fabio Pio, Jose-Luis Beristain-Hernandez, Pietro Mezzatesta, Maria Cristina Saffioti, Andrea Belli, Francesco Izzo, Michele Ammendola, Francesca Vescio, Graziano Ceccarelli, Michele De Rosa, Fabio Rondelli, Andrea Tufo, Raffaele Galleano, Maurizio De Luca, Enrico Lodo, Dario Parini, Agostino Fernicola, Elio Jovine, Laura Mastrangelo, Christian Cotsoglou, Beatrice Torre, Mario Annecchiarico, Luigi Bonanni, Davide Chiappori, Federico Paniccia, Edoardo Saladino, Elisa Bertilone, Lorenzo Epis, Marco Filauro, Carolina Cecchi, Rosita De Vincenti, Massimo Fedi, Paolina Saullo, Massimiliano Fabozzi, Andrea Morini, Maurizio Zizzo, Marco Giordano, Gianmarco Palini, Luigi Veneroni, Gian Luca Grazi, Antonio Taddei, Luca Tirloni, Gennaro Mazzarella, Giulia Bacchiocchi, Edoardo Baldini, Alberto Brolese, Francesca Notte, Stefan Patauner, Giovanni Scotton, Riccardo Caruso, Yolanda Quijano, Emilio Vicente, Stefano Cantafio, Egidio Miranda, Federica Maffeis, Paolo Ubiali, Jaqueline Velkoski, Francesco Tandoi, Alessandro Capozucco, Alessandro Liguori, Alessandro Puzziello, Mariafelicia Valeriani, Chiara Bettini, Martina Fricano, Sarah Molfino, Giuseppe Evola, Luigi Piazza, Marco Vacante, Alessandro Cucchetti, Giorgio Ercolani, Giuliano La Barba, Andrea Benedetti Cacciaguerra, Federico Mocchegiani, Marco Vivarelli, Giammauro Berardi, Giuseppe Ettorre, Alessandro Anselmo, Silvio Caringi, Leandro Siragusa, Paolo Bianco, Fulvio Calise, Salvatore Spiezia, Alberto Patriti, Filippo Petrelli, Luca Viganò, Antonio Giuliani, Stefano Berti, Daniele Celi, Valentina Marchese, Edoardo Maria Muttillo, Paolo Mercantini, Andrea Scarinci, Celia Caula, Margarida Casellas Robert, Santiago Lopez Ben, Tommaso Campagnaro, Mario De Bellis, Andrea Ruzzenente, Roberto Montalti, Gianluca Rompianesi, Roberto Troisi, Francesco Orlando, Giovanni Vennarecci, Francesco Ardito, Francesco Razionale, Benedetto Ielpo, Luca Risi PMC · DOI: 10.1007/s00464-025-11769-3 · 2025-06-16 ## TL;DR This study explores how different devices are used for liver surgery in minimally invasive techniques, comparing laparoscopic and robotic approaches across hospitals. ## Contribution The study provides insights into the current practices and device preferences for liver parenchyma transection in minimally invasive surgery. ## Key findings - Laparoscopic techniques remain dominant for liver resections, including major hepatectomies. - CUSA is preferred for major resections, while ultrasonic shears and bipolar devices are used for minor ones. - Robotic surgery often uses Maryland bipolar forceps and vessel sealers, with hybrid methods addressing limitations. ## Abstract 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. The Italian Society of Endoscopic Surgery (SICE) endorsed a cross-sectional internet-based survey targeting general and Hepato-Pancreato-Biliary surgeons. 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. 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. The online version contains supplementary material available at 10.1007/s00464-025-11769-3. ## Full-text entities - **Diseases:** -MILS (MESH:D017093) ## Figures 3 figures with captions in the complete paper: https://tomesphere.com/paper/PMC12287225/full.md --- Source: https://tomesphere.com/paper/PMC12287225