Robotic Resection of a Type IIIB Klatskin Tumor

A single institution's experience with robotic resections of biliary tract cancers: an analysis of the short-term outcomes and long-term survival

INTRODUCTION

Perihilar cholangiocarcinoma, intrahepatic cholangiocarcinoma (IHCC), and gall bladder cancer are difficult malignancies to treat and are characterized by a tendency for local recurrence and a generally unfavorable prognosis. Surgical resection offers the only potential cure, conventionally performed via the open approach. Although minimally invasive approaches show promise, data remain limited.

METHODS

With the institutional review board's approval, we prospectively followed 100 patients between 2013 and 2023 who underwent robotic surgical resection for perihilar, IHCC, and gallbladder cholangiocarcinoma. Data are presented as median (mean ± SD). Significance was accepted at P ≤ .05.

RESULTS

The median patient age was 70 years, and the median operative duration was 333 min, with an estimated blood loss of 200 mL. Importantly, no unplanned conversions occurred, and only 1 intraoperative complication occurred within the IHCC cohort. The median length of stay was 4 days. There were a total of 19 postoperative complications and 19 readmissions within 30 days. Additionally, there were 3 in-hospital mortalities and 5 90-day mortalities. R0 resection was achieved in 87% of patients and R1 resection in 13%. At a median follow-up of 36 months, 62% of patients demonstrated disease-free survival, whereas 6% continued to live with the disease, and 32% did not survive.

CONCLUSION

Our experience demonstrates the feasibility and safety of robotic resection for these complex malignancies, yielding promising short-term outcomes. Further investigation is required to ascertain the long-term oncologic outcomes.

Robotic Left Hepatectomy with En Bloc Biliary Resection and Roux-en-Y Hepaticojejunostomy: A Technique of Portal Venous Tangential Vascular Reconstruction

BACKGROUND

Robotic technology is increasingly utilized in perihilar cholangiocarcinoma treatments, requiring expertise in minimally invasive liver surgeries and biliary reconstructions. These resections often involve vascular and multiple sectoral bile duct reconstructions. Minimally invasive vascular repairs are now emerging with promising outcomes, potentially altering criteria for selecting minimally invasive hepatobiliary tumor resections. In this multimedia article, we describe our technique of robotic portal venous tangential primary reconstruction with right sectoral bile duct unification ductoplasty for the treatment of perihilar cholangiocarcinoma using the robotic approach.

METHODS

The robotic technique was chosen in this operation with preoperative anticipation of needing vascular resection and reconstruction due to left portal vein tumor involvement. Additionally, a Roux-en-Y hepaticojejunostomy to the right anterior and posterior sectoral duct was planned for biliary reconstruction. Proximal and distal vascular control of the portal vein bifurcation was obtained by placing vascular bulldog clamps across the main and right portal veins. Once an R0 vascular margin was obtained on the left portal vein, portal bifurcation was tangentially repaired. Perfusion to the liver was then restored, and left hemihepatectomy with en bloc extrahepatic biliary resection was carried out, followed by Roux-en-Y hepaticojejunostomy reconstruction to the right anterior and posterior sectoral bile ducts, as a single anastomosis.

RESULTS

The operation was uneventful without vascular or biliary complications. Robotic unification ductoplasty circumvented the need for multiple anastomoses.

CONCLUSION

The robotic approach for left-sided perihilar cholangiocarcinoma resections, requiring precise biliovascular management, is safe, feasible, and efficient. This method demonstrates the potential of robotic techniques as an alternative to traditional open surgery.

Robotic Biliary Resection for Type I Choledochal Cyst With Dual Hepaticojejunostomy

The distal bile duct was isolated and transected with a frozen section examination confirming the absence of malignancy. Attention was then shifted to constructing a 60 cm Roux limb by first identifying and transecting the proximal jejunum 40 cm from the ligamentum of Treitz. A side-to-side stapled jejunojejunostomy anastomosis was completed. The Roux limb was transposed toward the porta hepatis through an antecolic approach.

Robotic Hepatectomy plus Biliary Reconstruction for Bismuth Type III and Type IV Hilar Cholangiocarcinoma: State of the Art and Literature Review

BACKGROUND

In Bismuth type III and IV Hilar Cholangiocarcinoma (III-IV HC), surgical resection is the only chance for long-term survival. As the surgical procedure is complex and Robotic-Assisted Surgery (RAS) may be particularly suitable in this setting, the aim of this study is to evaluate the potential benefits of RAS in III-IV HC in terms of post-operative outcomes.

METHODS

We conducted a systematic review using the PRISMA checklist for article selection. We searched the PubMed database and included only studies with clinical data about the treatment of III-IV HC using RAS.

RESULTS

A total of 12 papers involving 50 patients were included. All cases were Bismuth IIIa (n = 18), IIIb (n = 27) or IV type (n = 5) and underwent hepatectomy with biliary confluence resection and reconstruction. The mean operative time was 500 minutes with a conversion rate of 4%. The mean hospital stay was 12.2 days, and the morbidity and 30-day mortality rate were 61.9% and 2%, respectively. Over a mean follow up period of 10.1 months, 9/18 cases experienced recurrence (50%).

CONCLUSIONS

RAS for III-IV HC is safe and feasible, at least if performed by experienced surgeons on selected cases. The oncological outcomes appear acceptable, given the aggressiveness of this pathology, but further studies are needed to fully elucidate the exact role of robotics in this setting.

Robotic Klatskin Type 3A Resection with Biliary Reconstruction: Description of Surgical Technique and Outcomes of Initial Series

INTRODUCTION

Minimally invasive resection for perihilar cholangiocarcinoma is an emerging technique that requires both mastery in minimally invasive liver resection and biliary reconstruction. Due to technical difficulties in biliovascular dissection, radical portal lymphadenectomy and the need for fine suturing during bilioenteric anastomosis, this type of resection is generally not performed laparoscopically, even at high-volume, liver-surgery centers.1-3 In modern literature, a detailed, operative description of robotic technique for this operation with outcome data is lacking. This video article demonstrates a pure robotic Klatskin Type 3A resection with clinical outcomes of our initial series.

VIDEO

A 77-year-old man presented with jaundice and findings of bilateral, intrahepatic, ductal dilation (Right > Left). Radiological imaging showed a type 3A Klatskin tumor with associated thrombosis of the right, anterior portal vein. A further endoscopic evaluation with cholangioscopy confirmed a high-grade Bismuth 3A biliary malignant stricture. Endoscopic drainage was achieved with placement of two, 7-French, 15-cm, plastic, endobiliary stents. A 3-D anatomical liver reconstruction showed a 2-cm mass located in the area of right, anterior, sectoral, Glissonean pedicle with standardized, future, liver-remnant (left hepatic lobe) volume of 50%. The patient was placed supine on the operating table. General endotracheal anesthesia was administered. After exclusion of metastatic peritoneal disease with diagnostic laparoscopy, cholecystectomy and systematic radical portal lymphadenectomy were first completed with a goal to obtain more than six lymph nodes. After appropriate portal lymphadenectomy, the common bile duct was isolated and transected at the level of pancreatic head. The plastic, endobiliary stents were removed, and a distal common bile duct margin was sent for a frozen-section examination to rule out distal extension of the cholangiocarcinoma. A small, accessory, right, hepatic artery lateral to the main portal vein was ligated with locking clips and removed together with the adjacent nodes and lymphatic bearing tissues. The intrapancreatic portion of the distal common bile duct was suture closed once the distal common bile duct margin was confirmed to be negative for neoplasia by the frozen-section examination. The proximal bile-duct dissection commenced cephalad toward the hilar bifurcation. Once the biliary bifurcation has been adequately dissected and detached from the hilar plate, the distal, left, hepatic duct was then transected near the base of the umbilical fissure to gain an R-0 resection margin. A second frozen-section specimen was obtained from the left, hepatic duct cut edge to ensure an absence of infiltrating tumor cells on the future, bile-duct remnant side. Division of short, hepatic veins off the inferior vena cava (IVC) were next completed. Once the line of hepatic-parenchymal transection was confirmed by using indocyanine green administration, the right hepatic artery and portal vein were ligated and clipped. The liver, parenchymal transection began with a crush-clamp technique utilizing robotic, fenestrated bipolar forceps and a vessel-sealing device. Preservation of the middle hepatic vein is always the preferred technique to avoid congestion of the left medial sector of the liver. The entire right hepatic lobe and the caudate lobe were removed en bloc. A large, Makuuchi ligament was isolated and divided by using a robotic, vascular-load stapler once the liver is open-booked. Finally, the root of the right hepatic vein was exposed and transected flush to the IVC by using another load of robotic vascular stapler. The biliary reconstruction then began by creating a 60-cm, roux limb for a hepaticojejunostomy bilioenteric anastomosis. A side-to-side, stapled jejunojejunostomy was created by using two applications for robotic 45-mm, blue load staplers. The common enterotomy was closed with running barbed sutures. The roux limb was then transposed retrocolically toward the porta hepatis. A single end-to-side hepaticojejunostomy anastomosis was created with running absorbable 4-0 barbed sutures. Finally, a closed suction abdominal drain was placed before closing.

RESULTS

The operative time was approximately 8 hours with 150 ml of blood loss. The postoperative course was unremarkable. The final pathology report confirmed a moderately differentiated perihilar cholangiocarcinoma with negative resection margins. Ten lymph nodes were harvested. No nodal metastasis or lymphovascular invasion was found. Since 2021, we have undertaken robotic resection of Klatskin 3A tumor in four patients with a median age of 70 years. All patients presented with jaundice, and they mainly underwent preoperative biliary drainage using ERCP. The median operative duration was 508 minutes with estimated blood loss of 150 ml. R-0 resection margins were obtained in all patients. One patient suffered from postoperative complications requiring treatment of line sepsis using intravenous antibiotics. We did not find a 90-day mortality in this series. At a median follow-up period of 15 months, all of the patients were alive without any evidence of disease recurrence.

CONCLUSIONS

Robotic resection of Type 3A Klatskin tumor is safe and feasible with appropriate experience in robotic hepatobiliary surgery, as demonstrated in this video article.

Robotic Type 3B Klatskin Tumor Resection: Technique of Unification Ductoplasty for Roux-en-Y Biliary Reconstruction

BACKGROUND

Application of robotic platform for perihilar cholangiocarcinoma is an emerging technique requiring expertise in both minimally invasive hepatic resection and biliary reconstruction. Due to oncological principles of trying to achieve tumor-free margins during cholangiocarcinoma operation, surgeons often find multiple sectoral bile ducts above the hilar plate that need to be reconstructed. Creating multiple oligomilimeter hepaticojejunostomy anastomoses is not only technically very challenging but also associated with an increased risk for postoperative bile leak and subsequent anastomotic stricture mandating reinterventions.

METHODS

Technical maneuvers to reduce the number of biliary anastomosis had been previously described in open surgical literature. Minimally invasive technique such as simple unification ductoplasty, however, has not been described laparoscopically or robotically.

RESULTS

We demonstrated a successful unification ductoplasty during a robotic type 3B Klatskin tumor resection according to Bismuth-Corlette classification. Creation of multiple anastomoses in this type of operation was able to be avoided.

CONCLUSION

Robotic platform facilitates ductoplasty for biliary reconstruction during Klatskin tumor resection.

The role of robotic surgery for the treatment of hilar cholangiocarcinoma: A systematic review

Background

The role of robotic surgery (RS) for hilar cholangiocarcinoma (HC) is under investigation. Surgical resection is the only curative modality of treatment but extremely complex and high risk of morbidity and mortality may occur. The aim of this study is to perform a systematic review of perioperative and oncological outcomes of RS for HC, across a comprehensive range of outcomes reported in recent literature.

Materials and Methods

PRISMA checklist was used as a basis for writing the systematic review and studies’ selection. Literature documenting RS for HC was analyzed by searching PubMed and Cochrane Library from 2009 to May 2022. The search terms, either independently or in combination, were used according to PICOT framework. The target population are patients treated with robotic surgical approach for HC.

Results

12 studies with 109 patients were included after screening process. The Bismuth classification in all series except one was: 21 type I, 7 type II, 12 type IIIa, 26 type IIIb and 4 type IV. Mean operative time for a total of 21 patients was 644 minutes. Other two case series reported a median operative time of 375 with a console time of 276 minutes. Mean blood loss for case reports and two case series was 662 milliliters. Blood transfusion rate for all operation was 33.3%. Overall Conversion rate was 2.8%. Pooled post operative morbidity and mortality was 39.8% and 1.8% respectively. Mean LOS for case reports and one case series for a total of 17 patients was 16 days. R0 resection rate for the 11 papers was 74.3%. Seven out of 12 studies reported on the oncological follow up: median observation time ranged from 5 to 60 months, recurrence rate was 52.6% (range 0-90%) reported only in 19 patients (10/19).

Conclusions

RS for HC was feasible and safe. However, although this systematic review could not be conclusive in most of the analyzed items, RS for the treatment of HC could represent the best tool for a future meticulous and precision surgery. The review’s results certainly indicate that further research in urgently is required on this field.

Analysis of surgical approach and tumor distance to margin after liver resection for colorectal liver metastasis

This study was undertaken to compare tumor distance to margin after robotic vs. open hepatectomy for colorectal liver metastases (CLM) and to determine the relationship between perioperative variables, surgical approach and tumor distance to margin with overall survival. With IRB approval, we followed 56 patients who underwent a robotic or open hepatectomy for treatment of CLM. The relationships between the tumor distance to margin, operative approach, perioperative variables and survival was determined. The robotic approach yielded greater margins than the open approach (p = 0.04). The robotic vs. open approach had an operative duration of 375 vs. 269 min (p = 0.05), ICU length of stay (LOS) of 0 vs. 1 day (p = 0.01), and hospital LOS of 4 vs. 7 days (p = 0.04). Patients with a tumor distance to margin of ≤ 1 mm and 1.1-9.9 mm had an estimated median survival of 49 months and 24 months, respectively. Estimated median survival for patients with tumor distance to margin of ≥ 10 mm has not been reached but is > 84 months. The use of the robotic approach is associated with greater tumor distance to margin and shorter hospital LOS, but with longer operations. The robotic approach does not compromise oncological margins during resection for CLM.