Robotic extended left hepatectomy and Roux-en-Y hepaticojejunostomy for hilar cholangiocarcinoma after neoadjuvant treatment

Robotic liver resection is among the most complex procedures in hepatobiliary surgery. Hilar cholangiocarcinoma is the most common malignant neoplasm of the biliary tract. Surgical resection remains the only curative treatment, but neoadjuvant therapy, including immunotherapy, is being used more frequently. Liver resection combined with complete extrahepatic bile duct resection, lymphadenectomy, and biliary reconstruction represents the current standard surgical treatment. Minimally invasive liver resection is a feasible and safe technique and has been used to treat several types of liver neoplasms. However, technical limitations and oncologic concerns have limited the adoption of minimally invasive techniques for the treatment of hilar cholangiocarcinoma. Since 2012, we have used minimally invasive techniques for the management of hilar cholangiocarcinoma . The aim of this video is to present a robotic left hepatectomy extended to the caudate lobe, combined with lymphadenectomy and Roux-en-Y hepaticojejunostomy.

This video demonstrates the technical aspects of a robotic extended left hepatectomy. A 74-year-old man presented with jaundice. MRI showed a 4.6 cm tumor involving the hepatic hilum. The tumor was deemed inoperable at another medical facility, and neoadjuvant treatment with durvalumab plus gemcitabine and cisplatin was initiated. After six cycles of treatment, the tumor had shrunk and patient was referred to our care. The multidisciplinary team opted for surgical treatment. A robotic approach was proposed and consent was obtained.

The procedure consisted of standard lymphadenectomy and skeletonization of the portal triad. The common bile duct was divided, and the distal bile duct was sent for frozen section, which was negative. Biliary stents were removed and sent for culture. Proximal and distal bile ducts were closed to prevent bile spillage. The left portal vein was occluded by the tumor and was divided with a vascular stapler to obtain free margins. The left hepatic artery was ligated and divided between hemolocks, and ischemic delineation of the left liver was seen and confirmed with fluorescence after indocyanine green injection. The liver was then transected under intermittent Pringle maneuver using robotic shears and bipolar forceps with saline irrigation. The caudate lobe was removed en bloc with the surgical specimen. The middle and left hepatic veins were divided with a stapler. The right bile duct was divided within the liver substance, resulting in two separate bile ducts, right anterior and posterior. The surgical specimen was removed and the Roux-en-Y was prepared. The jejunal loop was brought to the upper abdomen in an antecolic fashion, and hepaticojejunostomy was performed with a 5-0 PDS running suture.

The total operating time was 320 minutes. The Pringle maneuver was used intermittently for 24 minutes. Time to complete the hepaticojejunostomy was 27 minutes. The estimated blood loss was 140 mL, and no transfusion was required during or after surgery. Recovery was uneventful, and the patient was discharged on postoperative day 5. No bile leakage was observed. Pathology confirmed a 4.2 x 3.0 cm cholangiocarcinoma with free surgical margins (T2N1). The patient is well and shows no sign of disease 8 months after the procedure. Robotic left hepatectomy extended to the caudate lobe, combined with lymphadenectomy and Roux-en-Y hepaticojejunostomy, is safe and feasible. This complex procedure should be performed by experienced surgeons in both open and robotic surgery. This video shows the steps required to perform this complex operation.