Robotic left trisectionectomy with lymphadenectomy and Roux-en-Y hepaticojejunostomy for intrahepatic cholangiocarcinoma

We present a video of a robotic left trisectionectomy with lymphadenectomy and Roux-en-Y hepaticojejunostomy for an intrahepatic cholangiocarcinoma. A 54-year-old woman presented with abdominal pain. MRI revealed a 7.6 cm single intrahepatic cholangiocarcinoma occupying the central liver. PET-CT showed a tumor confined to the liver with no evidence of spread. The tumor was deemed unresectable and neoadjuvant treatment with durvalumab plus gemcitabine and cisplatin was initiated. After 6 months of treatment, the tumor showed a clear response with a reduction in size and reduced activity on PET-CT. Despite infiltration of the hilar plate, the tumor spared the right posterior pedicle. The multidisciplinary team decided for liver resection. Based on the liver volumetry and preoperative images, a left trisectionectomy was chosen. A robotic approach was suggested, and consent was obtained.

Robotic left trisectionectomy was performed by complete dissection of the hepatic hilum, including the right anterior hepatic artery, portal vein, and bile duct. A lymphadenectomy was also performed, resulting in skeletonization of the hilar plate. The left hepatic artery, which originated from the gastric artery, was ligated separately from the hepatoduodenal ligament. During the liver transection, we found that the common bile duct was in close contact with the tumor and could not be spared. A Roux-en-Y hepaticojejunostomy was therefore necessary for technical and oncologic reasons. However, the jejunal loop was brought up to the right upper quadrant under moderate tension and we decided to fix the jejunal loop. We had previously experienced bile leaks in patients with jejunal loop tension and sutured the jejunal loop to the retroperitoneal ligament under the remnant liver, to the right diaphragmatic pillar and to the ligamentum Arantius to eliminate any sign of tension.

The total operating time was 407 minutes, and the estimated blood loss was 340 ml. An intermittent Pringle maneuver was performed and the total Pringle time was 64 minutes. No transfusion was required during or after surgery. Pathology revealed a single 6.5cm cholangiocarcinoma (T3N1) with free margins. Recovery was uneventful and the patient was discharged on postoperative day 9. No bile leakage was observed.

Robotic left trisectionectomy with Roux-en-Y hepaticojejunostomy is safe and feasible. This complex procedure should be performed by experienced surgeons, both in open and robotic surgery. The intrahepatic hepaticojejunostomy can sometimes be under tension, which can lead to postoperative bile leakage. Sutures to fix the jejunal loop can help to relieve this tension and reduce the risk of postoperative bile leakage.