Robotic-assisted laparoscopic hepatic hilar cholangiocarcinoma (Bismuth-Corlette Ⅲb) radical resection

Abstract

Study objective

To demonstrate a case for the successful use of the robotic-assisted laparoscopic hepatic hilar cholangiocarcinoma (Bismuth-Corlette Ⅲb) radical resection.

Design

Stepwise demonstration with narrated video footage, including left hemi hepatectomy, total caudate lobectomy, extrahepatic biliary tract resection and reconstruction, hepaticojejunostomy, cholecystectomy, and hepatic hilar lymph node dissection.

Setting

The First Affiliated Hospital of Harbin Medical University.

Case presentation

A 34-year-old female patient developed icteric skin and sclera without obvious triggers, accompanied by dark urine, and light-colored loose stools. She had a dull pain in the upper abdomen and lost 2.5 ​kg weight in this period. Before admission, she had accepted percutaneous transhepatic cholangial drainage (PTCD) in other hospital, with two drainage tubes collecting 500 ml of bile per day in total. Due to the liver-enhanced CT scan suggesting proximal bile duct obstruction, space-occupying lesions of the hilar bile duct are considered, with no exclusion of cholangiocarcinoma. Routine preoperative laboratory examinations were performed after admission. The total bilirubin level was 75.5 μmol/L (normal range, 3.4–21 μmol/L) and the direct bilirubin level was 40.8 μmol/L (normal range, 0.01–3.4 μmol/L); alanine aminotransferase level was 282.6 U/L (normal range, 5–40 U/L); aspartate aminotransferase level was 124.2 U/L (normal range, 8–40 U/L); γ-glutamyl transpeptidase level was 79.8 U/L (normal range, 10–60 U/L); CA19-9 level was 62.68 U/mL (normal range, 0–37 U/mL).

Intervention

Since the first robot-assisted hepatectomy was reported in 2002, the use of robot-assisted surgery in the hepatobiliary department has grown rapidly.^1,2 However, robot-assisted surgery for hepatic hilar cholangiocarcinoma radical resection is rarely reported. Although the tumor volume is not large, hepatic hilar cholangiocarcinoma radical resection is regarded as one of the most challenging operations because it includes major hepatectomy, hepatic hilar lymph node dissection, and bile duct reconstruction.^3,4. The operative area is located at the core of the first porta hepatis, possessing a close anatomic relationship with the hepatic artery and portal vein, which greatly increases the difficulty and risk of the operation. In addition, for such tumors located at such a unique place, operating space for surgeons is objectively limited, and the radical resection of tumors can only be achieved by ensuring the absolute negative margin of the bile duct and the precise dissection of the hepatic hilar lymph node. The emergence of the robotic-assisted system has solved this problem⁵. With the three core technologies: naked eye 3D high-definition vision, turnable surgical instruments, and intuitive movement, the robotic-assisted system helps surgeons operate in the limited and narrow space under the best vision through the flexible conversion of robotic arms from multiple angles. During the operation, the patient was placed in a supine position, and our conventional trocar layout used in liver resection was adopted (Fig. 1). The liver was suspended by pulling round ligaments during the operation, and Pringle maneuver was used for first hepatic portal occlusion. We completely removed the left hemi liver, caudate lobe, diseased biliary tract and hepatic hilar lymph node. The hepaticojejunostomy was completed after biliary duct reconstruction. Through the application of the robot-assisted system, we can identify the anatomical structure more clearly, avoid collateral damage, shorten the intraoperative time, and improve the prognosis of patients. The results were as follows: The procedure was successfully performed with one 5 cm and five 0.8 cm incisions. The patient had a good recovery, getting rid of the drainage tube on the left on postoperative day 7, and another drainage tube on the right on day 9. Suffering with no complications, the patient was discharged on day 10. The pathology report showed moderately or poorly differentiated adenocarcinoma in the hepatic hilar bile duct, which invaded surrounding liver tissue and nerve. None of the nine lymph nodes we harvested presented metastasis at the final pathology report. All the incisional edges we sent for examination during the operation were reported negative.

Conclusion

Robotic-assisted laparoscopic hepatic hilar cholangiocarcinoma (Bismuth-Corlette Ⅲb) radical resection gives full play to the advantages of the robotic-assisted system, providing better vision and more delicate operations, which makes the tissue dissection safer and less damage, so as to accelerate the postoperative recovery of patients and bring better therapeutic effects to them.