Abstract
Background
Minimally invasive resection for perihilar cholangiocarcinoma is a complicated and technically demanding surgical procedure. Radical surgical resection is regarded as the best treatment for hepatic hilar cholangiocarcinoma.1,2 Right hepatectomy with caudate lobe resection is necessary as the treatment for bismuth IIIa hilar cholangiocarcinoma.3 The left-liver-first anterior radical modular orthotopic right hemihepatectomy (LARMORH), which can simplify surgical steps and decrease procedural difficulty, may be a better choice for Bismuth IIIa hilar cholangiocarcinoma.4 However, there are no reports of this approach using robotic technique for this operation. We will provide a detailed introduction to this method through this video.
Methods
A 45-year-old female patient was diagnosed with a hilar cholangiocarcinoma. Following a 7-day percutaneous biliary drainage of the left intrahepatic bile duct and obtaining informed consent, we performed a robotic radical resection of the HCCA using the LARMORH approach. The patient was positioned supine with the entire bed elevated 20° and tilted 15° to the left. Trocars were placed in position (Fig. 1). After entering the abdominal cavity, it was explored for tumor metastasis. The surgery adopted a left approach, initially exploring the left hepatic artery and vein to further assess resectability. After confirming resectability, the right hepatic artery and gastroduodenal artery (GDA) were dissected. The common bile duct was dissected and transected at its distal end, ensuring R0 surgical margins. Lymph nodes were cleared from the foot side to the head side, confirming the metastasis to the lymph node group 13a, so we further cleared the group 16 and 9 lymph nodes.5 Subsequently, we approached the resection of the right half and the entire caudate lobe with the reverse thinking of left hepatic resection mode, preserving only the left branch of the portal vein and left hepatic artery, and dissecting the liver tissue along the resection plane of the left liver. After transection of the left hepatic duct, the activity space of the left liver was larger and the caudate lobe could be better exposed. The Spiegel lobe was lifted to the right in a “turn the page” fashion for in situ resection of the entire caudate lobe and the right half of the liver. Finally, a bilioenteric anastomosis was performed using the Roux-en-Y method.
Results
Robotic right hepatectomy with caudate lobectomy was successfully performed in 450 min, with an estimated blood loss of 200 ml. The histological grading was determined as T1aN1M0 (stage IIIB) on the basis of postoperative pathological biopsy results. The patient achieved a satisfactory postoperative recovery and was discharged on the 14th postoperative day without any major complications. Following the operation, the patient received capecitabine chemotherapy according to the Chinese Society of Clinical Oncology (CSCO) criteria.
Since September 2022, our team has completed three radical resections for Bismuth IIIa HCCA using this technique. All patients achieved a satisfactory postoperative recovery without any further complications.
Conclusions
Robotic left-liver-first anterior radical modular orthotopic right hemihepatectomy for Bismuth IIIa HCCA is both safe and feasible. This method may provide a new surgical approach for patients with type IIIA HCCA or liver diseases requiring right hemihepatectomy combined with total caudate lobectomy.
Similar content being viewed by others
References
Wang Z, Tao H, Wang J, et al. Laparoscopic right hemi-hepatectomy plus total caudate lobectomy for perihilar cholangiocarcinoma via anterior approach with augmented reality navigation: a feasibility study. Surg Endosc. 2023;37(10):8156–64.
Sucandy I, Younos A, Lim-Dy A, et al. Robotic klatskin type 3A resection with biliary reconstruction: description of surgical technique and outcomes of initial series. Ann Surg Oncol. 2023;30(13):8559–60.
Wang D, Xiong F, Wu G, et al. The value of total caudate lobe resection for hilar cholangiocarcinoma. Int J Surg. 2023;110:385–94.
Liu X, Hu Z, Zhou X, et al. Application of a new approach for laparoscopic resection of Bismuth IIIa hilar cholangiocarcinoma. J Laparoendosc Adv Surg Tech A. 2023;33(10):969–74.
Xiong Y, Jingdong L, Zhaohui T, Lau J. A consensus meeting on expert recommendations on operating specifications for laparoscopic radical resection of hilar cholangiocarcinoma. Front Surg. 2021;8:731448. https://doi.org/10.3389/fsurg.2021.731448.
Acknowledgments
We gratefully acknowledge the First Affiliated Hospital of Chongqing Medical University for the clinical data support.
Funding
The Natural Science Foundation of Chongqing (CSTB2023NSCQ- BHX0131) and the Postdoctoral Cultivation Project of the First Affiliated Hospital of Chongqing Medical University (CYYY-BSHPYXM-202315). There are no potential conflicts of interest to declare.
Author information
Authors and Affiliations
Contributions
GL wrote the study; KZ, YL, GL, and ZW chose and edited the video; BZ gave the final endorsement for the version that is to be published.
Corresponding authors
Ethics declarations
Disclosure
There is no potential conflict of interest to declare.
Informed consent
Permission was granted by the patient for the release of this report and any related images for publication.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Supplementary file2 (MP4 343485 KB)
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Li, G., Zong, K., Li, Y. et al. Robotic Right Hepatectomy with En Bloc Caudatectomy for Bismuth IIIa Hilar Cholangiocarcinoma: A Video Demonstration of Left-Liver-First Anterior Radical Modular Orthotopic Right Hemihepatectomy. Ann Surg Oncol (2024). https://doi.org/10.1245/s10434-024-15407-5
Received:
Accepted:
Published:
DOI: https://doi.org/10.1245/s10434-024-15407-5