Perihilar cholangiocarcinoma is one of the most complex challenges for hepatobiliary surgeons due to both anatomical and oncological reasons. Surgical resection remains the only potentially curative treatment and requires complex procedures such as major hepatectomy with extrahepatic bile duct resection and lymphadenectomy.
The introduction of minimally invasive methods has revolutionized liver surgery, offering benefits such as reduced postoperative pain, shorter hospital stays, and faster recoveries compared to open surgery. Among these techniques, robotic-assisted surgery has become more popular due to its distinct advantages, including superior 3D visualization, enhanced instrument articulation, and improved surgeon ergonomics. These features are especially valuable for complex operations such as liver resection for perihilar cholangiocarcinoma, where lymphadenectomy, vascular control, and biliary reconstruction are essential.
We present a video of a robotic right hepatectomy with lymphadenectomy and Roux-en-Y hepaticojejunostomy for perihilar cholangiocarcinoma. A 69-year-old woman presented with jaundice. MRI showed dilatation of the intrahepatic bile ducts, stenosis of the right portal vein, and compensatory hypertrophy of the left liver. The findings were consistent with perihilar cholangiocarcinoma classified as Bismuth IIIa. After ERCP drainage failed, percutaneous biliary drainage was performed and the jaundice resolved. She was then transferred to our care. The multidisciplinary team opted for upfront surgical treatment. A right hemihepatectomy with lymphadenectomy and Roux-en-Y hepaticojejunostomy was proposed. A robotic approach was indicated and consent was obtained. The decision to perform a right hepatectomy instead of a right trisectionectomy was based on specific aspects of this case. The bifurcation of the right and left hepatic arteries occurred early in the hepatic hilum. The left hepatic artery and the segment 4 artery (a branch of the left hepatic artery) were not involved by the tumor. There was also no involvement of the segment 4 bile duct. Additionally, segment 4 was extremely hypertrophied. Therefore, removal of segment 4 was not justified for oncological or anatomical reasons. Liver volumetry showed that the future liver remnant volume was 59%, indicating adequacy. Because the bilirubin level was normal, the patient had no liver disease, and no neoadjuvant therapy was used, liver function was considered adequate based on volumetry alone.
The procedure included hilar lymphadenectomy and skeletonization of the portal triad. The common bile duct was divided, and the distal bile duct was sent for frozen section, which was negative. Biliary stents were removed and sent for culture. Proximal and distal bile ducts were closed to prevent bile spillage. The right hepatic artery was ligated and divided between hemolocks. The right portal vein was ligated, resulting in ischemic delineation of the right liver, which was confirmed with fluorescence imaging after indocyanine green injection. The right liver was then mobilized, and the percutaneous biliary drain was removed. Small retrohepatic hepatic veins were controlled with hemolocks. The liver was then transected under intermittent Pringle maneuver using robotic shears and bipolar forceps with saline irrigation. Larger vessels, including distal part of the middle hepatic vein and hepatic vein from segment 8 (V8), were controlled with hemolocks. The Spiegel lobe was preserved because the tumor was far from the Spiegel lobe bile duct, which was draining into the left bile duct above the bifurcation. Additionally, the left liver was massively hypertrophied, making its resection difficult and hazardous. The left bile duct was divided within the liver substance, and the proximal bile duct was sent for frozen section biopsy, which was negative. Finally, the right hepatic vein was divided with a stapler. The surgical specimen was removed, and the Roux-en-Y was prepared. The jejunal loop was brought to the upper abdomen in an antecolic fashion, and hepaticojejunostomy was performed with a 5-0 PDS running suture. The jejunal loop was fixed to the retroperitoneum, the left liver was fixed to the abdominal wall, and the abdominal cavity was drained.
The total operating time was 350 minutes with an estimated blood loss of 210 ml. An intermittent Pringle maneuver was performed and the total Pringle time was 42 minutes. No transfusion was required during or after the operation. Recovery was uneventful and the patient was discharged on postoperative day 12. No bile leakage was observed. Pathology revealed a perihilar cholangiocarcinoma measuring 2.2 cm with free surgical margins (T2bN1). The patient received adjuvant therapy with capecitabine. The patient is well with no evidence of disease 11 months after the procedure. Robotic right hepatectomy with lymphadenectomy and Roux-en-Y hepaticojejunostomy is safe and feasible. This complex procedure should be performed by surgeons experienced in both open and robotic hepatobiliary surgery.
