Robotic Right Hepatectomy for Peri-Hilar Cholangiocarcinoma after Liver Venous Deprivation.

Abstract

Background: Recent innovations such as robotic platforms and liver venous deprivation (LVD) have the potential to improve the management and surgical treatment of peri-hilar cholangiocarcinoma (Ph-CCA). Robotic platforms integrate the operative field view with intraoperative ultrasound and preoperative 3D planning. ^1-4 LVD is increasingly preferred over portal vein embolization for better liver hypertrophy outcomes in both speed and percentage.⁵ This video demonstrates the feasibility of fully robotic right hepatectomy with common bile duct resection and reconstruction for Ph-CCA after LVD.

Patients: A Bismuth 3a Ph-CCA was diagnosed in a 74-year-old female with jaundice. Preoperatively, the patient underwent 3D volumetry and planning and percutaneous drainage of left biliary ducts. The future remnant liver volume increased from 38 to 53% of total liver volume after LVD.

Technique: Four robotic trocars and one laparoscopic port were placed, and the da Vinci Xi system was docked. En-bloc regional lymphadenectomy was performed, followed by isolation of the hepatic pedicle elements. After mobilization of the caudate lobe and section of the distal common bile duct, the en-bloc right hepatectomy was carried out. A single biliodigestive anastomosis was performed on B2-3-4 on an antecolic Roux-&-Y jejunal loop. The operative time was 810 min. The blood loss was 500 mL. The patient was discharged on postoperative day 16. The pathology confirmed pT2b N0 (0/11 nodes) R0r R0b^6,7 G2 Ph-CCA.

Conclusion: Although this was a very demanding and challenging approach for both the patient and the surgical team, this video demonstrates the feasibility of this management and probably sets the goal for a new standard of care.