Intraoperative Strategy under Complex Vascular Adhesion for Laparoscopic Radical Resection of Bismuth-Corlette Type IIIb Perihilar Cholangiocarcinoma

Summary

The protocol presents a step-by-step laparoscopic protocol for radical resection of Bismuth-Corlette type IIIb perihilar cholangiocarcinoma. The procedure integrates preoperative PTCD, complex vascular dissection and repair, and biliary reconstruction for application in high-volume hepatobiliary centers.

Abstract

Perihilar cholangiocarcinoma (pCCA) is a highly challenging malignancy, often requiring extensive hepatic resection to achieve curative treatment. This article presents a case of Bismuth-Corlette type IIIb pCCA in a 53-year-old male patient who underwent a laparoscopic left hemihepatectomy with caudate lobe resection, lymphadenectomy, and Roux-en-Y hepaticojejunostomy. Preoperative percutaneous transhepatic biliary drainage (PTCD) was performed to relieve obstructive jaundice and improve liver function. Intraoperatively, the tumor was found to be densely adherent to the proper hepatic artery (PHA) and right hepatic artery (RHA), necessitating meticulous vascular dissection. An intraoperative arterial injury was successfully repaired using microsurgical suturing under laparoscopic guidance. Complete lymphadenectomy was conducted at stations 1, 3, 7, 8, 9, 12, and 13. The caudate lobe was entirely resected to ensure oncologic radicality. The postoperative course was uneventful, except for a transient bile leak that resolved with conservative management. Final pathology confirmed R0 resection with no lymph node metastasis. This case demonstrates the technical feasibility and safety of advanced laparoscopic approaches in complex pCCA, emphasizing the importance of preoperative planning, vascular control, and multidisciplinary collaboration.

Introduction

Perihilar cholangiocarcinoma (pCCA) is the most common subtype of extrahepatic bile duct cancer, accounting for approximately 50%-60% of all cholangiocarcinomas. It primarily arises at the confluence of the common hepatic duct and the left and right hepatic ducts¹. Due to its unique anatomical location adjacent to the proper hepatic artery, portal vein, and bilateral hepatic ducts, the tumor frequently invades vascular and biliary structures, resulting in significant surgical challenges² .

Currently, curative resection remains the only treatment modality associated with long-term survival for pCCA. Specifically, left hemihepatectomy combined with caudate lobectomy and regional lymphadenectomy is considered the standard surgical approach for Bismuth-Corlette type IIIb pCCA patients^3,4. The necessity of caudate lobectomy based on anatomical resection principles has been confirmed by multiple studies, demonstrating its role in significantly increasing R0 resection rates and reducing local recurrence⁵. However, dense adhesion or encasement of the tumor around the right hepatic artery and the proper hepatic artery markedly increase intraoperative risk. The limited operating space under laparoscopy further challenges meticulous dissection and vascular preservation, demanding high technical expertise from the surgeon^6,7.

With the advancement of laparoscopic techniques, minimally invasive radical resection for hilar cholangiocarcinoma has gradually been performed by experienced surgeons. Nevertheless, due to high surgical risks and a steep learning curve, such procedures are mainly confined to specialized high-volume centers⁸. Previous literature has primarily focused on right hemihepatectomy, with relatively few reports on laparoscopic left hemihepatectomy combined with caudate lobectomy, especially in cases complicated by close adherence or adhesion to the proper and right hepatic arteries⁹.

This study presents a case of laparoscopic left hemihepatectomy combined with caudate lobectomy and regional lymphadenectomy for type IIIb hilar cholangiocarcinoma. The major intraoperative challenges included safe and effective separation of the hepatic arteries adherent to the tumor, biliary resection, and hilar dissection. The procedure aimed to achieve oncological radicality while minimizing intraoperative bleeding and complications. This case serves as a valuable technical reference for the laparoscopic management of complex hilar cholangiocarcinoma.

CASE PRESENTATION:
The patient was a 53-year-old male laborer who had been living in a rural area with moderate access to healthcare. He presented to the hospital on May 14, 2024, with a 14-day history of progressive jaundice involving the skin and sclera. The patient reported persistent upper abdominal discomfort and fatigue, accompanied by significant yellow discoloration of the skin and sclera. He also noted an unintentional weight loss of approximately 5 kg over the past 3 months. There were no symptoms of fever, chills, or melena.

The patient had no prior history of liver disease, viral hepatitis (HBV or HCV), cirrhosis, or fatty liver disease. There was no known family history of liver or other cancers. He denied a history of smoking, alcohol consumption, or any other chronic underlying diseases such as diabetes or hypertension. There was no prior surgical history.

An abdominal CT scan performed at an outside facility prior to admission revealed a mass-like lesion in the left hepatic lobe near the hepatic hilum. Cholangiocarcinoma was suspected based on imaging and clinical presentation. The initial diagnosis was perihilar cholangiocarcinoma.

On physical examination, the patient appeared moderately nourished, with marked jaundice of the skin and sclera. There was no lower extremity edema. The abdomen was soft with mild tenderness in the upper abdomen, without palpable masses. The liver and spleen were not enlarged, and there were no signs of ascites. The patient had not received any treatment prior to admission, and this was his first visit to our hospital.

Diagnosis, Assessment, and Plan: The patient was admitted due to progressive skin and scleral jaundice. On admission, physical examination revealed marked jaundice. Laboratory investigations showed elevated cholestatic liver enzymes and tumor markers: CA19-9 was 116 U/mL, gamma-glutamyl transferase (GGT) 183.00 U/L, alkaline phosphatase (ALP) 391.00 U/L, total bilirubin (TBIL) 296.50 µmol/L, and direct bilirubin (DBIL) 183.12 µmol/L. Other tumor markers, coagulation profile, renal function, and transaminase levels were within normal limits. Following admission, enhanced liver MRI with hepatocyte-specific contrast (EOB-MRI) and magnetic resonance cholangiopancreatography (MRCP) were performed, which revealed significant stenosis of the hilar bile duct, consistent with perihilar cholangiocarcinoma (also known as Klatskin tumor).

Preliminary diagnosis: Perihilar cholangiocarcinoma (Klatskin tumor)

Tumor staging: According to the 8th edition of the American Joint Committee on Cancer (AJCC) staging system¹⁰, the tumor was staged as cT2NxM0, Bismuth-Corlette Classification¹¹ Type IIIb (involving the left hepatic duct, with no right hepatic duct involvement)

Initial management: Upon admission, the patient received intravenous cefoperazone to prevent infection, hepatoprotective agents, and supportive care, including fluid and electrolyte management. To alleviate biliary obstruction, the patient underwent percutaneous transhepatic cholangial drainage (PTCD).

Reassessment after PTCD: Post-drainage laboratory evaluation showed ALT 43.50 U/L, TBIL 151.76 µmol/L, and DBIL 102.17 µmol/L, indicating sufficient hepatic function for surgical intervention.

Planned surgical procedure: After comprehensive evaluation of the patient's general condition and imaging findings, the following laparoscopic surgical procedure was scheduled: Laparoscopic left hemihepatectomy, Caudate lobe resection, Hilar lymphadenectomy, Cholecystectomy, Hepaticojejunostomy.

Protocol

Prior to the surgery, the patient provided written informed consent. The surgical procedure was approved by the Institutional Review Board (IRB) of Dongguan Bin-Hai-Wan Central Hospital.

1. Preoperative preparation

1. Imaging evaluation
   1. EOB-MR: Magnetic resonance imaging (MRI) with liver-specific contrast agent (gadoxetate disodium, Gd-EOB-DTPA) was performed to assess the location and extent of the lesion. The tumor appeared as an ill-defined mass located in the medial segment of the left hepatic lobe near the hepatic hilum, measuring approximately 40 mm x 30 mm (Figure 1A).
   2. On the arterial phase, the lesion showed heterogeneous enhancement, with close proximity to the right hepatic artery, although no clear encasement of the artery was observed (Figure 1B). In the portal venous phase, the lesion exhibited progressive enhancement. The right branch of the portal vein was clearly visualized, while the left portal vein branch was poorly defined (Figure 1C).
   3. MRCP: Magnetic resonance cholangiopancreatography (MRCP) demonstrated a stricture involving the left hepatic duct and the biliary confluence. There was intrahepatic bile duct dilatation, more pronounced in the left lobe. No intraductal filling defects were seen, although the left hepatic duct was poorly visualized (Figure 2).
   4. CTA: A contrast-enhanced computed tomography angiography (CTA) of the abdomen was performed to evaluate hepatic arterial anatomy. No vascular anatomical variations were noted. However, the left hepatic artery appeared significantly narrowed (Figure 3A), and the right hepatic artery was in close proximity to the tumor without evidence of encasement (Figure 3B).
2. Percutaneous transhepatic cholangiographic drainage (PTCD)
   NOTE: In this case, the patient presented with progressive obstructive jaundice, with a total bilirubin (TBIL) level as high as 296.50 µmol/L. Imaging revealed biliary obstruction near the hepatic hilum. PTCD was performed preoperatively with the following objectives: to lower serum bilirubin, reduce hepatocellular burden, and improve liver function in preparation for surgery; by relieving biliary pressure and stasis, PTCD reduces the risk of preoperative cholangitis and other bile-related infections; cholangiography during the procedure helps define the level and extent of obstruction, aiding in classification (e.g., Bismuth-Corlette) and surgical planning; establishes external biliary drainage to improve surgical outcomes in complex operations, such as resection for perihilar cholangiocarcinoma.
   1. PTCD was performed by experienced ultrasound physicians under real-time ultrasound guidance.
   2. Assess coagulation profile (INR, PT, platelet count) and correct any abnormalities. Evaluate biliary dilation and select the appropriate access route (right anterior segmental bile duct). Administer local or conscious sedation anesthesia as needed.
   3. Puncture was performed subcostally on the right side under ultrasound guidance, targeting a dilated intrahepatic duct.
   4. Injection of contrast agent was done to delineate biliary anatomy and confirm the site of obstruction.
   5. A 10 Fr drainage catheter was inserted over a guidewire, enabling partial or complete external drainage of bile.
   6. Continuous drainage was ensured, and bile output (volume and color) was monitored. Tracking of liver function, inflammatory markers, and bilirubin levels was carried out. Routine flushing of the catheter was performed to prevent blockage or retrograde infection.
   7. Excessive or rapid bile drainage may lead to electrolyte imbalances or low bile syndrome; drainage volume should be carefully adjusted based on bilirubin reduction. Monitoring for signs of infection was done, and antibiotics were administered if necessary. For long-term drainage, ensure proper catheter care and regular replacement to avoid complications.

2. Anesthesia preparation

1. A comprehensive preoperative evaluation was conducted by the anesthesiology team. The patient had no cardiopulmonary dysfunction, allergies, or airway abnormalities. Based on the patient's condition and expected surgical complexity, general anesthesia with endotracheal intubation was planned.
2. The anesthesia team was alerted to potential intraoperative challenges, including: prolonged operative time, intraoperative bleeding due to vascular dissection, and hemodynamic instability requiring vasopressor support
3. Anesthesia was induced and maintained using standard agents. Vital signs, arterial pressure, central venous pressure, and urine output were continuously monitored. No anesthesia-related complications occurred during the procedure
4. Under general anesthesia with endotracheal intubation, the patient was placed in a supine position with legs apart, and head elevated 15° (reverse Trendelenburg position).

3. Trocar placement

1. Under general anesthesia with endotracheal intubation, after establishing a pneumoperitoneum through a periumbilical incision using a Veress needle technique, carbon dioxide insufflation was maintained at 12-15 mmHg.
2. A 12-mm trocar was inserted at the umbilicus for the laparoscope to provide a panoramic view of the abdominal cavity. Additional working ports were placed under direct laparoscopic visualization to optimize access and instrument maneuverability, usually as follows: 12-mm main working port in the right midclavicular line below the costal margin, allowing primary dissection instruments and ultrasonic scalpel placement, 5- or 12-mm port in the left midclavicular line below the costal margin for assisting with retraction and exposure of the left hepatic lobe and caudate process, one or two 5-mm accessory ports in the right anterior axillary line and right lower quadrant to facilitate liver mobilization, vascular control, and lymphadenectomy.
   NOTE: Ports are spaced adequately (typically ≥ 8 cm apart) to prevent instrument interference and optimize ergonomics. The port configuration allows effective exposure of the hepatic hilum, hepatic arteries, portal vein branches, and bile ducts, facilitating precise dissection during the left hemihepatectomy and caudate lobectomy.

4. Surgical procedure

1. Inspection of the liver revealed no visible tumor on the liver surface.
2. The liver was mobilized by freeing the falciform ligament and the second hepatic hilum, fully exposing the second hepatic hilum. The left coronary ligament and the triangular ligament were divided.
3. Liver was suspended, and separate adhesions of the gallbladder fossa were done.
4. Under ultrasound guidance, an incision of the duodenal lateral peritoneum was made until the inferior vena cava was exposed.
5. Lymph nodes of station 13 were dissected, and adhesions around the hepatic hilum were released.
6. The lesser omentum sac was incised, and the gastroduodenal artery, common hepatic artery, and left gastric vein were identified and incised. The proper hepatic artery could not be dissected because of adhesion to the surrounding tumor tissue (Figure 4).
7. The right gastric vein was ligated and divided, then the hepatogastric ligament was incised.
8. The common hepatic artery was isolated and suspended. Lymph nodes of stations 8, 7, and 9 (which are fused) were dissected.
9. Isolation and suspension of the gastroduodenal artery was continued. Tumor adhesion to the right hepatic artery was done, and the proper hepatic artery was discovered; blunt dissection was not feasible. Attempt careful, sharp dissection with scissors, which still might be difficult (Figure 5). Intraoperative frozen pathology of adhesions showed inflammatory tissue.
10. After cholecystectomy, an attempt was made to separate the right hepatic artery and proper hepatic artery from the cystic artery stump.
11. Sharp dissection continued along with ligation of vessels supplying the tumor; dissection remains difficult; continue combined blunt and sharp dissection of arterial adhesions.
12. Dissection of the lymph nodes of station 12 was done.Continued combined blunt and sharp dissection was done around arterial adhesions. After evaluation, the proper hepatic artery and the right hepatic artery were freed (Figure 6).
13. Division of the distal common bile duct was done, and the distal bile duct margin was sent for intraoperative pathology. The pathology report was negative, and the bile duct stump was sutured.
14. Dissection of the surrounding tissue and lymph nodes of the common bile duct was done.
15. Continued dissection of the right hepatic artery was done. During dissection, the right hepatic artery ruptured and was repaired with 5-0 vascular sutures (Figure 7). Intraoperative ultrasound confirmed good blood flow, and the dissection continued until the right hepatic artery was completely freed.
16. Continued combined blunt and sharp dissection of adhesions around the proper hepatic artery was done to expose and suspend the proper hepatic artery.
17. After isolating the left hepatic artery, it was ligated with 7-0 silk and vascular clips, then divided with scissors (Figure 8).
18. Continuous dissection of lymph nodes stations 3 and 1 was done, and by now, lymph nodes stations 12, 13, 8, 7, 9, 3, and 1 have been cleared.
19. Continuous dissection of the left portal vein was done and tumor invasion found. The root of the left portal vein was ligated with a 7-0 silk suture (Figure 9).
20. Ligaments around the caudate lobe were mobilized and ligation/division corresponding to short hepatic veins was done.
21. The ischemic line of the left and right hepatic lobes was marked with electrocautery.Intraoperative ultrasound confirmed the middle hepatic vein, tumor location, and portal vein.
22. The first hepatic hilum was clamped. Using an ultrasonic scalpel, the liver parenchyma was transected along the pre-marked line.
23. Identification of the middle hepatic vein was done, and ligation and division of the segment 4b vein were carried out (Figure 10).
24. Continued transection of liver parenchyma along the left side of the middle hepatic vein was done.
25. Left and right hepatic ducts were exposed, and it was found that the tumor involved the biliary confluence and the left hepatic duct. Transection of the right hepatic duct, approximately 0.5 cm from the tumor margin, was done along with the transection of the bile duct at the caudate lobe (Figure 11).
26. The left portal vein was divided, and the proximal margin of the right hepatic duct was sent for frozen pathology. The result was negative.
27. Transection of the caudate lobe liver parenchyma was done, followed by ligation and division of the corresponding short hepatic veins and ligamentous attachments (Figure 12).
28. Continued transection of liver parenchyma along the left side of the middle hepatic vein was done until the left hepatic vein was exposed.
29. Isolation and division of the left hepatic vein with a stapler was done. A complete left hemihepatectomy and caudate lobectomy were done, fully exposing the middle hepatic vein and inferior vena cava (Figure 13).
30. The left portal vein margin was sent for pathology. The result was negative. Suturing of the defect with 5-0 vascular sutures was done.
31. Using a bulldog clamp, the proximal and distal portal vein was clamped. Sutures at the defect site were loosened to allow blood drainage to flush potential tumor cells from the portal vein. After flushing, ligation of the sutures was performed, and it was confirmed that no bleeding occurred.
32. Irrigation of the liver transection surface and abdominal cavity with warm saline was done, and hemostasis was achieved using bipolar cautery. At this point, lymph node stations 12, 13, 8, 7, 9, 3, and 1 were dissected, and left hemihepatectomy with caudate lobectomy was completed (Figure 14A,B).
33. After making a 6 cm incision above the umbilicus, layer by layer through the abdominal wall, a wound protector was inserted, and the specimen was extracted. The specimen was placed in a retrieval bag.
34. The jejunum was pulled through the incision and transected 15-20 cm distal to the ligament of Treitz, bringing the distal jejunal limb to the hepatic hilum, ensuring no tension.
35. A side-to-side jejunojejunostomy 50-60 cm distal to the proximal jejunum was performed along with a Roux-en-Y hepaticojejunostomy between the jejunal limb and the bile duct to prevent bile reflux.
36. The abdominal incision was closed with interrupted figure-of-eight sutures. Under laparoscopy, the jejunum was opened and alignment of the anastomosis site with the bile duct was done. Single-layer continuous mucosa-to-mucosa anastomosis using 5-0 Vicryl absorbable sutures was performed.
37. Irrigation of the abdominal cavity with warm saline was done. Drainage tubes were placed near the liver transection surface and hepaticojejunostomy site. The laparoscope was withdrawn, and the release of pneumoperitoneum was done. The trocar incisions were closed.

5. Postoperative procedures

1. Immediate postoperative monitoring: The patient was transferred to the surgical intensive care unit (SICU) for continuous monitoring of vital signs, urine output, and neurological status. Hemodynamic parameters, including blood pressure, heart rate, central venous pressure, and oxygen saturation, were closely observed.
2. Liver function and drain output: Liver function tests (ALT, AST, TBIL, DBIL, ALP, GGT) were performed daily during the first 5 postoperative days. Drainage volume, color, and character were monitored every 8 h to detect potential bile leakage or hemorrhage. Drain fluid was also tested for serum amylase to exclude pancreatic injury.
3. Antibiotic and hepatoprotective therapy: Broad-spectrum intravenous antibiotics (e.g., cefoperazone-sulbactam) were administered for 5-7 days postoperatively. Hepatoprotective agents such as glutathione and glycyrrhizin were used intravenously to facilitate hepatic recovery.
4. Anticoagulation and thrombosis prophylaxis: Low-molecular-weight heparin (LMWH) was initiated 24 h after surgery for deep vein thrombosis (DVT) prevention. Compression stockings were also applied as adjunct prophylaxis.
5. Nutritional support: The patient was kept nil per os (NPO) for the first 1-2 postoperative days, receiving total parenteral nutrition (TPN). Upon absence of bile leakage or ileus, clear liquids were introduced on postoperative day (POD) 3, gradually advancing to a soft diet.
6. Early mobilization: Passive limb exercises were encouraged on POD 1, sitting up in bed on POD 2, and assisted ambulation was initiated from POD 3 to reduce pulmonary complications and thromboembolism risk.
7. Drain management: Drains were removed between POD 5 and 7 if the output was serous, less than 50 mL per 24 h, and there were no signs of bile leakage or infection. Drain amylase and bilirubin levels were rechecked prior to removal.
8. Bile Leakage and Hemorrhage Surveillance: In cases of bilious drainage or increasing bilirubin, contrast-enhanced CT or MRCP was performed. Suspected hemorrhage (e.g., hemoglobin drop, hypotension) prompted urgent imaging and hematologic intervention.
9. Discharge criteria: The patient was discharged after stabilization of vital signs, adequate oral intake, pain controlled by oral analgesics, normalization of liver function tests, absence of active drainage, and independent ambulation.
10. Follow-up and surveillance: Outpatient follow-up was scheduled at 1, 3, and 6 months postoperatively, including physical examination, liver function tests, CA19-9 monitoring, and abdominal imaging (CT or MRCP). Adjuvant therapy was considered based on final pathology and multidisciplinary discussion; however, the patient declined related treatment.

Results

The patient successfully underwent laparoscopic left hemihepatectomy with caudate lobe resection, regional lymphadenectomy, and Roux-en-Y hepaticojejunostomy. The total operation time was approximately 480 min, with an estimated blood loss of 300 mL. No blood transfusion was required, and the procedure was completed without conversion to open surgery.

Intraoperative challenges included dense adhesions between the tumor and the proper hepatic artery as well as the right hepatic artery, which re...

Discussion

Radical resection remains the only potentially curative treatment for perihilar cholangiocarcinoma (pCCA), especially in Bismuth-Corlette type IIIb tumors, where extended left hepatectomy and caudate lobectomy are required to achieve an R0 margin^12,13. This case highlights the technical feasibility and oncologic safety of performing such a complex operation laparoscopically, even in the presence of dense vascular adhesions.

One of the ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Absorbable Suture (Vicryl)	3-0 / 4-0	Johnson & Johnson	V-348
Anesthesia Gas (N2O + O2)	Nitrous Oxide + Oxygen	Airgas	N2O/O2
General Anesthesia Drugs	Various Anesthesia Drugs	Roche	Propofol
High-frequency Cutting	—	Ethicon	Harmonic ACE+
Non-absorbable Suture (Prolene)	4-0	Ethicon	PROLENE 8698
Povidone Iodine Solution	500 mL	Betadine	BP-500
Surgical Forceps	Straight, Locking	Surgical Instruments	SIC-925
Surgical Scissors	Straight, Sharp Tip	Aesculap	KLS Martin 5245
Surgical Sterile Drapes	40x40 cm	3M	Surgical Drapes
Titanium Clips	Small size	Medtronic	Endo GIA