Robotic Resection of Left Intraductal Papillary Cholangiocarcinoma with Roux-en-Y Hepaticojejunostomy: Standardized Technique of Liver Resection with Biliary Reconstruction.

Background: Intraductal papillary cholangiocarcinoma is a preinvasive type of biliary tract cancer with a relatively favorable prognosis, requiring complete resection of the involved bile ducts and corresponding liver segments (Christodoulou et al. in J Gastrointest Surg, 2024; Sucandy et al. in Collab Study Ann Surg Oncol 31:81-89, 2024; Magistri et al. in Eur J Surg Oncol 49:107002, 2023; Sucandy et al. in Ann Surg Oncol 30:8559-8560, 2023). When located in the perihilar region, mild cholangitis and segmental or lobular biliary obstruction are often the presenting findings. Herein, we demonstrate our technique for robotic resection of intraductal cholangiocarcinoma with biliary reconstruction and portal lymphadenectomy.

Patients And Methods: A 78-year-old woman presented with recurrent fever and left hepatic duct filling defects with ipsilateral biliary dilation, concerning for intraductal cholangiocarcinoma. Computed tomography (CT) and magnetic resonance imaging (MRI) indicated a lesion within the left hepatic duct involving biliary bifurcation. After the portal lymphadenectomy, the distal common bile duct was transected with scissors. A choledochoscope was inserted into the proximal extrahepatic duct to visualize the tumor location and extent. After obtaining inflow control, the anatomical left hepatectomy was undertaken with caudate resection. An ultrasonic dissector was used for parenchymal transection. Once the specimen was removed, a retrocolic Roux-en-Y-hepaticojejunostomy was fashioned to the right anterior, right posterior, and accessory right dorsal hepatic duct as a single anastomosis following unification ductoplasty technique. We did not feel the need to place biliary stents owing to the relatively large composite size of the bile ducts after ductoplasty (more than 1 cm in total). The caudate lobe biliary branch was about 6-7 mm in size, which is an acceptable diameter in our practice to perform a robotic anastomosis without placing a biliary ductal stent.

Results: The operation was completed uneventfully with 50 ml of blood loss. After an uncomplicated recovery, she was discharged home on postoperative day six. She is currently two years post-resection without recurrent disease.

Discussion: The level of proximal bile duct transection is determined by a combination of detailed preoperative radiological evaluation (using MRI/MRCP/CT scan) and intraoperative clinical investigation using choledoschope/Spyglass biliary endoscope. The lumen of the bile duct is endoscopically visualized using Spyglass to determine proximal end of tumor involvement. Once this is endoscopically visualized, robotic camera is then directed and focused to search transilluminating light originated from the end of the Spyglass. Gentle external tapping on the proximal bile duct wall using robotic scissors is applied to confirm the transection level while observing the endoscopic view at all time. After each transection of the bile duct, cut ends (bile duct stumps/margins) were evaluated and confirmed to be negative through intraoperative frozen section pathological examination, as the oncological primary goals.

Conclusions: Robotic resection of intraductal cholangiocarcinoma with biliary reconstruction and portal lymphadenectomy is safe and feasible with excellent outcomes. We believe this approach will become an alternative to the conventional open operation.