Robotic Resection of Type IV Perihilar Cholangiocarcinoma. Moving Toward the Most Complex Minimally Invasive Technique in Biliary Cancer Surgery.

Background: Minimally invasive techniques are not being adopted in biliary cancer surgery for perihilar cholangiocarcinoma (Klatskin tumor) because of the technical complexity of tumor extirpation, the need for fine hepaticojejunostomy biliary reconstructions, and concerns about oncological radicality that could affect long-term survival. Although technical reports have been published for resections of type I-III Klatskin tumors using robotic approaches in the last 5 years, technical descriptions of resections of type IV Klatskin tumors are very limited in the literature.^1-5 This is because type IV perihilar cholangiocarcinoma involves secondary biliary/hepatic ducts above the hilar plate bilaterally, requiring a very difficult resection, followed by more than one fine hepaticojejunostomy anastomoses. Thus, this operation is undertaken via an unpopular laparoscopic method. The emergence of minimally invasive robotic techniques, with their technical advantages over laparoscopy enables complex resections to be completed. Herein, we describe an application of a minimally invasive robotic biliary surgery technique for resection of type IV perihilar cholangiocarcinoma.

Methods: A 71-year-old otherwise healthy man initially presented to his medical oncologist with pruritus, obstructive jaundice, and weight loss. Workup, including computed tomography/magnetic resonance imaging scans, endoscopic ultrasonography, biliary endoscopy, endoscopic retrograde cholangiopancreatography, and positron-emitting tomography, revealed Bismuth-Corlette type IV perihilar cholangiocarcinoma without any evidence of extrahepatic disease. Preoperative drainage using bilateral endoscopic retrograde cholangiopancreatography stenting was completed with normalization of his liver function panel. The patient had undergone 1 year of systemic chemoimmunotherapy before the surgical referral. He showed no signs of disease progression and tolerable systemic side effects. The operative plan included robotic extended left hepatectomy en-bloc with caudate lobectomy, extrahepatic biliary resection, radical portal lymphadenectomy, and Roux-en-Y hepaticojejunostomy. The Pringle maneuver was not used in this operation because of the relatively hemostatic nature of the parenchymal division. However, isolated temporary vascular clamping of the main portal vein for 10 minutes was undertaken using a vascular bulldog clamp to facilitate and achieve left portal vein division, which was densely adherent to the hilar plate. 3-0 barbed permanent sutures were used for the bile duct closure and jejunojejunostomy anastomosis. 4-0 barbed absorbable sutures and 5-0 PDS sutures were used for the hepaticojejunostomy anastomoses.

Results: The operation was completed uneventfully without intraoperative or postoperative complications. The patient's recovery in the hospital was uneventful, and he was successfully discharged on postoperative day 7 with his abdominal drain removed before hospital discharge. The patient reported no complications during office follow-ups. At 1 year after resection, he has no evidence of disease.

Conclusion: The application of a robotic technique is safe and feasible for the treatment of Bismuth-Corlette type IV perihilar cholangiocarcinoma with excellent short-term outcomes. We believe that, with experienced robotic hepatobiliary surgeons and well-selected patients, this most complex biliary cancer resection will find surgical refinements and future utilization.