Laparoscopic Radical Resection for Hilar Cholangiocarcinoma with Portal Vein Invasions

Summary

Here, we present a protocol for laparoscopic radical resection and vascular reconstruction of hilar cholangiocarcinoma with portal vein invasion, providing reproducible surgical guidance for clinical practice.

Abstract

Laparoscopic radical resection for hilar cholangiocarcinoma with vascular invasion is technically demanding but feasible in selected cases when performed by an experienced hepatobiliary surgical team. Precise minimally invasive technical execution and systematic surgical workflow organization are critical for mitigating surgical risks. We present a patient with Bismuth type IV HCCA with portal vein invasion who underwent a fully laparoscopic radical resection. The key surgical steps were as follows: (1) "en bloc" resection of hilar lymph nodes and the perihilar neural plexus; (2) segmental resection of the invaded portal vein followed by continuous suture reconstruction; and (3) microsurgical plasty of multiple bile duct orifices in conjunction with Roux-en-Y hepaticojejunostomy. The surgery was completed in 6 h, with an estimated blood loss of 200 mL and without conversion to open laparotomy. Postoperative pathological examination confirmed R0 resection with no lymph node metastases. No postoperative complications, including biliary leakage, haemorrhage, or infection, occurred. The patient remains under surveillance. Follow-up occurred at 1 month and 3 months after surgery, and subsequently occurs every 3 months. Assessments include liver function tests, tumour marker assays, and imaging (ultrasound, CT, or MRI).

Introduction

Cholangiocarcinoma is a highly heterogeneous malignancy originating from the epithelial cells of the bile ducts and gallbladder¹; hilar cholangiocarcinoma accounts for approximately 10%-15% of all primary liver cancers, second only to hepatocellular carcinoma². Owing to the high degree of malignancy and strong invasiveness of this disease, despite the gradual increase in diagnostic and therapeutic regimens, the overall survival and quality of life of patients remain unsatisfactory. R0 surgical resection is widely recognized as the only potentially curative treatment modality to achieve optimal long-term survival rates

Protocol

​The operation followed standard procedures and received ethics approval. This study was approved by the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University. Informed written consent was obtained from the patient. The reagents and the equipment used are listed in the Table of Materials.

1. Preoperative preparation

1. Patient preparation: Following induction of general anesthesia with endotracheal intubation, the patient was positioned in a modified supine posture: 30° right tilt with a reverse Trendelenburg orientation (head elevated 20°, feet lowered).
   NOTE: Sta....

Results

In this case report, total laparoscopic radical resection was successfully performed for Bismuth type IV hilar cholangiocarcinoma with portal vein invasion. Postoperative pathology confirmed R0 resection. The operation duration was 6 h, with 200 mL of intraoperative blood loss and without conversion to laparotomy (Table 1). Upon discharge, a re-examination of liver function revealed that the total bilirubin level was less than 30 µmol/L and the ALT level was less than 50 .......

Discussion

HCCA is a prevalent malignancy of the biliary tract, constituting approximately 50% of all biliary tract malignancies¹¹. Radical resection remains the sole potentially curative therapeutic modality. While traditional open surgery facilitates R0 resection under direct visualization, it necessitates a large incision, entails a prolonged recovery period, and is associated with a relatively high risk of multiple complications, consequently leading to extended hospital stays¹²

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Ablation electrode (multifunctional surgical dissector)	Nanchang Huaan Company	B1	Sterile, ethylene oxide sterilized, disposable
Alligaclip Absorbable Ligating Clip	Covidien	8886848813	Sterile, ethylene oxide sterilized, disposable
Barbed suture	Covidien	3-0/4-0	Sterile, ethylene oxide sterilized, disposable
Disposable non-absorbable ligating clips	Beijing Bohui Company	RJLK-S/RJLK-M	Sterile, ethylene oxide sterilized, disposable
Disposable staple cartridge 60	Tianjin Ruiqi Company	SRC60	Sterile, ethylene oxide sterilized, disposable
Electric laparoscopic linear cutting stapler and staple cartridge	Johnson (USA)	PSEE60A	Sterile, ethylene oxide sterilized, disposable
Trocar	Surgaid Medical?Xiamen?Co., Ltd	NPCM-100-12;NPVM-100-3-C	Sterile, ethylene oxide sterilized, disposable