Minimally invasive liver resections for hilar cholangiocarcinoma: a narrative review

Hilar cholangiocarcinoma has a severe prognosis and surgical treatment represents the only chance for cure. Unfortunately, surgery for Klatskin tumours is technically challenging as it often requires major liver resection and caudatectomy concomitant to the bile duct resection, standard lymphadenectomy, and ultimate assessment of resectability. Minimally-invasive techniques have been applied to almost all fields of hepatobiliary surgery with satisfactory intraoperative outcomes and advantages for patients. However, for hilar cholangiocarcinomas are the last area of resistance, since multiple difficult procedures need to be combined in a single operation. The objective of the study was to conduct a review of the available literature on minimally invasive liver resections for hilar cholangiocarcinoma. A literature search was performed in the PubMed database. The search words were (“Klatskin” OR “hilar cholangiocarcinoma”) AND (“laparoscopic” OR “minimally-invasive” OR “robotic” OR “robot-assisted”). Language restriction was applied to include only English literature, and publications up to March 2020 were considered. For both pure laparoscopy and robotics there are limited publications, mainly addressing the safety and feasibility in the setting of selected patients and carried out at expert centres. Data on operations requiring associated liver resections are still scant and scattered among case reports, small case series, and a handful of comparative studies. However, the preliminary data are promising. Conversion rates are acceptable, with most of the authors excluding from this approach locally advanced tumours such as Bismuth type IV or vascular invasion. Long operative time are expected decrease with experience, and no major intraoperative accidents have been reported. There are initial data on possible postoperative advantages in terms of reduced complications and length of stay; the robotic approach may facilitate difficult bilioenteric anastomoses and reduce postoperative bile leaks. The adequacy of lymphadenectomy and radical resections seems to be preserved, but long-term oncological data still lack. In conclusion, it is advocated further research on this topic to include a larger number of patients, standardize the technique especially for the most difficult steps and refine the reconstructive phase. However, the actual data should not foster theoretical hostility toward the implementation of minimally-invasive techniques in this setting, but rather support its stepwise advancements in expert centres.