Robotic-Assisted Radical Resection for Hilar Cholangiocarcinoma

Radical resection for hilar cholangiocarcinoma remains one of the most challenging procedures in hepatobiliary surgery. With advancements in surgical techniques and the promotion of multidisciplinary treatment models, its current management is characterized by the following aspects: Firstly, innovation in surgical techniques and conversion therapy, through combined approaches such as preoperative biliary drainage, selective portal vein embolization, vascular resection and reconstruction, and extended hepatectomy, have increased the conversion rate and radical resection rate for initially unresectable tumors¹. Secondly, minimally invasive surgery is progressing through ongoing exploration. Some teams have reported achieving an R0 resection rate of 86.3% with laparoscopic radical resection². Thirdly, anatomical complexity and surgical risks pose significant challenges. Hilar cholangiocarcinoma frequently involves the hepatic artery, portal vein, and biliary confluence, requiring precise dissection and reconstruction of vascular and biliary structures during surgery³. Moreover, the high risk of postoperative complications such as infection and anastomotic leakage demands considerable surgical expertise, making the procedure highly demanding.

In traditional minimally invasive surgery for hilar cholangiocarcinoma, laparoscopic surgery offers advantages such as faster postoperative recovery, reduced intraoperative blood loss, and a relatively high R0 resection rate; however, it is associated with longer operative times and a steep technical learning curve^4,5,6. Robotic-assisted surgery provides enhanced precision and maneuverability, resulting in significantly less blood loss than both laparoscopic and open approaches, as well as superior performance in complex reconstructive procedures. The robotic platform enables more accurate suturing, shorter anastomosis time, and a lower incidence of postoperative bile leakage. Nevertheless, it requires an extended learning period for surgeons and involves considerably higher costs for patients^7,8. For Bismuth type I hilar cholangiocarcinoma, robot-assisted radical resection demonstrates notable advantages in precision and minimal invasiveness, though its widespread adoption remains limited by technical challenges and economic barriers^9,10. In experienced medical centers, this approach can be considered a safe and feasible option.

This study aims to demonstrate the step-by-step robotic-assisted radical resection technique for Bismuth type I hilar cholangiocarcinoma. Briefly, this protocol is most suitable for early-stage (Bismuth I) disease and requires an experienced hepatobiliary robotic surgery team.

Patient characteristics

A 65-year-old male patient was admitted on February 22, 2025, presenting with "dark urine for 10 days, accompanied by jaundice of the skin and sclera and upper abdominal pain for 3 days." Laboratory investigations revealed: total bilirubin 275 µmol/L and CA19-9 262.0 U/mL. Magnetic Resonance Cholangiopancreatography (MRCP) demonstrated an irregular soft tissue mass in the proximal common bile duct (CBD), with dilation of the upstream biliary system. An irregular soft tissue nodule, measuring approximately 27 mm x 17 mm x 13 mm, was visualized in the proximal CBD, causing corresponding luminal occlusion (Figure 1 and Video 1). Abdominal non-contrast and contrast-enhanced Computed Tomography (CT) showed soft tissue lesions within the common bile duct, common hepatic duct (CHD), and cystic duct, associated with dilation of the upstream bile ducts, suggestive of possible cholangiocarcinoma (Figure 2 and Video 2). The walls of the common bile duct (specifically the supraduodenal and retroduodenal segments) and the common hepatic duct were heterogeneously thickened, with a localized soft tissue nodule measuring approximately 26 mm x 17 mm in cross-section. Enlarged lymph nodes were noted in the porta hepatis, with the largest measuring about 11 mm in short-axis diameter. Comprehensive evaluation led to a diagnosis of cholangiocarcinoma (Bismuth Type I), clinically staged as cT1N0M0 IA.

Following admission, percutaneous transhepatic cholangiodrainage (PTCD) was performed initially for biliary decompression. One week later, the patient underwent a "robotic-assisted radical resection for hilar cholangiocarcinoma" under general anesthesia with endotracheal intubation.

The surgical procedure was approved by the Ethics Committee of Qingyuan People's Hospital, Guangzhou Medical University. Written informed consent was obtained from the patient and family members, as approved by the hospital ethics committee. The condition was discussed with the patient and family members, and surgical treatment was performed based on the informed decision made. The consumables and the equipment used are listed in the Table of Materials.

1. Preoperative workup and biliary drainage

1. Perform percutaneous transhepatic cholangiodrainage to relieve biliary obstruction and reduce jaundice after admission.
2. Complete comprehensive preoperative evaluation and staging based on laboratory findings and multimodal imaging to confirm the diagnosis and surgical eligibility.

2. Surgical technique

1. Anesthesia and access
   1. Induce general anesthesia and position the patient supine with split legs and moderate reverse Trendelenburg positioning (following institutionally approved protocols).
   2. Deploy the surgical robotic system, arranging instrument Arms 1-4 from the patient'right to left. Assign the laparoscope to Arm 3 (Figure 3).
   3. Establish pneumoperitoneum and insert the initial laparoscopic port. Under direct vision, place five trocars.
      1. Insert an 8-mm trocar 2 cm below the right costal margin on the anterior axillary line for Arm 1.
      2. Place another 8-mm trocar 2 cm above the umbilicus on the right midclavicular line for Arm 2.
      3. Position the camera port 1 cm above the umbilicus using an 8-mm trocar and connect it to Arm 3.
      4. Insert a fourth 8-mm trocar 2 cm above the umbilicus on the left midclavicular line for Arm 4.
      5. Place a 12-mm assistant port 5 cm below the umbilicus on the right midclavicular line.
   4. Adjust trocar placement as needed according to the patient's anatomy and surgical needs.
2. Abdominal exploration
   1. Systematically inspect the abdominal cavity for any iatrogenic injury, ascites, or abnormalities.
   2. Identify the liver discoloration, PTCD catheter in the left hepatic lobe, distended gallbladder, and a firm mass (approximately 3.0 cm × 2.5 cm) in the proximal common bile duct with regional lymphadenopathy (Figure 4).
   3. Confirm the absence of distal common bile duct dilation, gastrointestinal abnormalities, or peritoneal nodules. Proceed with robot-assisted cholangiocarcinoma resection.
3. Mobilization, lymph node dissection, and duct division
   1. Perform a Kocher maneuver to mobilize the duodenum. Dissect lymph node station 13a.
   2. Open the hepatoduodenal ligament. Identify and expose the common hepatic artery and the gastroduodenal artery (GDA); then ligate and divide the GDA (Figure 5).
   3. Skeletonize the hepatoduodenal ligament, clearing lymphatic and connective tissues around the common hepatic artery (station 8) and within the ligament (station 12) (Figure 6).
   4. Carefully skeletonize the proper, right, and left hepatic arteries. Separate the common bile duct mass from the right hepatic artery, confirming no invasion¹¹.
   5. Expose the portal vein and confirm no tumor involvement. Mobilize, ligate, and divide the common bile duct near the pancreatic border. Send the distal margin for frozen section.
4. Cholecystectomy and duct division
   1. Retract the gallbladder using an atraumatic grasper. Dissect it from the fundus downward and free it from the gallbladder fossa (Figure 7).
   2. Separate the tumor from the right hepatic artery, preserving the right hepatic artery (Figure 8).
   3. Lower the hilar plate. Identify the left and right hepatic ducts.
   4. Transect the common hepatic duct with scissors superior to the confluence of the right and left hepatic ducts. Following transection, the orifices of the right anterior sectoral duct, right posterior sectoral duct, caudate duct(s), and left hepatic duct were clearly identified and individually cannulated with stent tubes to facilitate the subsequent hepaticojejunostomy (Figure 9).
   5. Resect the distal common bile duct (Figure 10) and send the biliary tumor specimen for frozen section analysis.
5. Biliary-enteric reconstruction
   1. Transect the jejunum 15 cm distal to the ligament of Treitz. Bring the Roux limb retrocolically to the hepatic hilum.
   2. Perform a hepaticojejunostomy between the hepatic duct confluence and the Roux limb. Place an internal biliary stent across the anastomosis.
   3. Suture the anterior and posterior walls of the anastomosis continuously using a 3-0 barbed suture (Figure 11).
   4. Create a side-to-side jejunojejunostomy 50 cm distal to the hepaticojejunostomy using a linear stapler (Figure 12).
6. Irrigation, drainage, closure, and specimen retrieval
   1. Irrigate the abdominal cavity thoroughly with warm saline. Achieve complete hemostasis.
   2. Place a closed-suction drain posterior to the hepatoduodenal ligament and exteriorize it through a separate incision in the right upper quadrant.
   3. Retrieve the surgical specimen through the umbilical port site. Verify that the counts of instruments and sponges are correct.
   4. Close the fascial defects at all trocar sites and then close all skin incisions.
7. Procedure completion
   1. Confirm the successful completion of the procedure without intraoperative complications.
   2. Document satisfactory anesthesia course, estimated blood loss of approximately 30 mL, and no requirement for blood transfusion.
   3. Review the specimen with the patient's family and send it for permanent pathological analysis. Transfer the patient to the Intensive Care Unit for postoperative monitoring. For the key procedures in steps 2.2-2.6 of this surgery, please refer to Video 3.

During the operation, we first dissected the hilar area, prioritizing the hepatic artery, and finally assessed the invasion of the hepatic artery and the resectability of the tumor. Meanwhile, we thoroughly dissected the lymph nodes, making the lesion resection easier and the surgery smoother. Finally, leveraging the robot's advantages, we performed cholangioenterostomy with precision, and the operation was successfully completed. The patient recovered and was discharged 9 days after the operation.

The patient experienced an intraoperative blood loss of approximately 30 mL. Postoperative management included anti-infection therapy, gastroprotective and hepatoprotective agents, choleretics, nutritional support, and drainage via catheter. The patient was discharged on postoperative day 9 with a PTCD drainage catheter in place. Postoperative pathology revealed a gallbladder and common bile duct tumor: Malignancy, consistent with extrahepatic cholangiocarcinoma based on HE morphology and immunohistochemistry (IHC). The tumor was poorly differentiated with focal sarcomatoid carcinoma features. Carcinoma diffusely invaded the entire duct wall thickness into the periductal fibroadipose tissue, with involvement of the gallbladder neck and focal perineural invasion. Examination of lymph nodes identified: 6 lymph nodes without metastatic carcinoma (0/6); Station 12A: 1 lymph node without metastasis (0/1); Stations 12 & 8: 7 lymph nodes, with 1 showing metastatic carcinoma (1/7); Station 13A: 1 lymph node without metastasis (0/1), and one separate tumor deposit. IHC results were: CK(+), CK8/18(+), CK19(+), Ki-67 (approximately 70%), P53 (approximately 80%), CK7(+). Tumor staging was pT3N1M0, Stage IIB. The patient recovered well postoperatively. Follow-up abdominal CT scan approximately 5 months postoperatively revealed postoperative changes consistent with prior resection for hilar cholangiocarcinoma, with satisfactory abdominal recovery (Video 4). The relevant outcomes of the surgical procedure are summarized in Table 1.

The discrepancy between the preoperative clinical stage (cT1N0M0) and postoperative pathological stage (pT3N1M0) in this case primarily stems from the inherent limitations of current imaging modalities in detecting microscopic tumor invasion and lymph node micrometastases. Preoperative imaging may fail to adequately identify microscopic tumor adherence to vasculature or minimal invasion of adjacent structures (leading to T-stage understaging), while also being insufficiently sensitive to detect micrometastases within lymph nodes (resulting in N-stage understaging). The final pathological diagnosis, established through comprehensive analysis of paraffin-embedded sections and immunohistochemistry, provides a more precise assessment of both tumor invasion depth and nodal metastasis status.

Figure 1: Preoperative magnetic resonance cholangiopancreatography (MRCP) images show the tumor location, indicated with a red square. Please click here to view a larger version of this figure.

Figure 2: Preoperative abdominal enhanced CT (arterial phase) images show the tumor location, indicated with a red square. Please click here to view a larger version of this figure.

Figure 3: Trocar configuration for robot-assisted radical resection of hilar cholangiocarcinoma. Please click here to view a larger version of this figure.

Figure 4: The tumor is located at the proximal end of the common bile duct, measuring approximately 3.0 cm × 2.5 cm. Please click here to view a larger version of this figure.

Figure 5: Exposure of the common hepatic artery (CHA), the proper hepatic artery (PHA), and the gastroduodenal artery (GDA). Ligation and division of the GDA. Abbreviation: GDA: gastroduodenal artery. CHA: common hepatic artery. PHA: proper hepatic artery. Please click here to view a larger version of this figure.

Figure 6: Lymphadenectomy of the hepatoduodenal ligament and skeletonization of the common hepatic artery (CHA), with the key area highlighted with a red square. Please click here to view a larger version of this figure.

Figure 7: Dissection and removal of the gallbladder from the gallbladder fossa. Please click here to view a larger version of this figure.

Figure 8: Separation of the tumor from the right hepatic artery (RHA) with preservation of the RHA. Abbreviation: RHA: right hepatic artery. CHA: common hepatic artery. PHA: proper hepatic artery. Identification of the right hepatic artery without injury. Please click here to view a larger version of this figure.

Figure 9: Transaction of the common hepatic duct with scissors superior to the confluence of the right and left hepatic ducts. Please click here to view a larger version of this figure.

Figure 10: Resection of the distal common bile duct and complete removal of the bile duct tumor. Please click here to view a larger version of this figure.

Figure 11: Anastomose each transected hepatic duct to the jejunum in a hepaticojejunostomy. Demonstration of bile duct stenting. Please click here to view a larger version of this figure.

Figure 12: Performing a side-to-side jejunojejunostomy. Please click here to view a larger version of this figure.

Table 1: Outcomes of the surgical procedure.

Video 1: Preoperative magnetic resonance cholangiopancreatography (MRCP) images of the patient. Please click here to download this file.

Video 2: Preoperative abdominal enhanced CT (arterial phase) images of the patient. Please click here to download this file.

Video 3: Intraoperative video recording of the key surgical procedures (corresponding to steps 2.2-2.6 in the text). Please click here to download this file.

Video 4: Postoperative abdominal CT imaging. Please click here to download this file.

Robotic-assisted systems demonstrate significant technical advantages in radical resection for hilar cholangiocarcinoma (PHCC), particularly in the precision of vascular dissection and biliary reconstruction^6,12. While traditional laparoscopy achieves minimally invasive outcomes (with literature reporting R0 resection rates of 86.3%), its two-dimensional visualization and limited instrument articulation create operative blind spots when manipulating critical structures such as the hepatic artery and portal vein^2,4. In this case, utilizing the Shenzhen Jingfeng Medical surgical robotic system's three-dimensional magnified view (10×) and tremor filtration function, successful separation of the tumor tightly adherent to the right hepatic artery was accomplished, with intraoperative blood loss of only 30 mL, significantly lower than the average 150-200 mL for laparoscopic procedures. Furthermore, employing wristed instruments with 7 degrees of freedom, a continuous biliary-enteric anastomosis was sutured using 3-0 barbed suture, which may have improved anastomotic efficiency with no postoperative bile leak. This robustly validates the unique value of robotic systems in microsurgical maneuvers, offering a safer surgical option for Bismuth type I hilar cholangiocarcinoma.

The discrepancy between the preoperative clinical stage (cT1N0M0) and postoperative pathological stage (pT3N1M0) in this study primarily stems from the inherent limitations of current imaging technologies in detecting microvascular invasion and nodal micrometastases. Although the final pathology indicated more advanced disease (pT3N1M0) than initially assessed, the successful achievement of R0 resection and complex biliary reconstruction with minimal intraoperative blood loss and no major complications demonstrates the technical feasibility and safety of robotic-assisted radical resection for hilar cholangiocarcinoma. This outcome underscores the platform's robustness in managing unforeseen surgical complexities.

However, this technology still faces practical limitations in terms of temporal cost, economic burden, and the learning curve. The operative time in this case was slightly prolonged, primarily due to system setup and complex procedural workflows¹³. Single-use consumable costs per procedure increase, significantly hindering adoption in primary hospitals. Moreover, surgeons require substantial experience in robotic hepatobiliary surgery to overcome the technical learning curve, necessitating concurrent mastery of open surgical anatomy and robotic operational logic. Notably, a discrepancy existed between the preoperative imaging (cT1N0M0, Stage IA) and postoperative pathology (pT3N1M0, Stage IIB), highlighting the persistent limitations of current imaging techniques in assessing nodal micrometastases¹⁴. For advanced Bismuth type III/IV tumors involving bilateral secondary bile ducts, whether robotics can achieve R0 resection requires validation through large-sample studies^15,16.

Addressing the aforementioned challenges, this robotic procedure optimized the surgical dissection pathway: Based on the "hilar resection" concept, an "artery-first" approach was adopted to prioritize skeletonization of the common hepatic artery and its branches, enabling early assessment of vascular invasion (the right hepatic artery was successfully preserved in this case). This reduced the risk of inadvertent injury compared to the traditional bile-duct-first pathway. Given the propensity for skip metastases in the hepatic hilar lymph nodes, systematic dissection of stations 8, 12, and 13a was performed (yielding 15 nodes total), revealing metastasis in one station 12 lymph node and one tumor deposit, thereby implementing the principle of individualized station-based dissection. Concurrently, the Roux-en-Y jejunal limb was lengthened to 50 cm, effectively mitigating reflux cholangitis. These synergistic strategies collectively enhanced procedural safety and oncological radicality.

Looking ahead, the evolution of robotic-assisted radical resection for hilar cholangiocarcinoma necessitates focus on technological integration and multidisciplinary collaboration. The fusion of intraoperative navigation systems (e.g., fluorescent cholangiography) with preoperative three-dimensional reconstruction technology can enable real-time localization of the biliary stump and precise planning of hepatic transection margins, thereby improving R0 resection rates. The commercialization of Chinese robotic systems holds promise for further reducing equipment costs, while AI-assisted operational modules may accelerate the learning curve. In accordance with the multidisciplinary team (MDT) model recommended by the China Consensus 2025, establishing an integrated management pathway encompassing neoadjuvant therapy, robotic surgery, and targeted therapy is paramount. This is especially critical for patients downstaged by conversion therapy, where the robotic system's millimeter-level precision in vascular reconstruction offers an irreplaceable advantage. As these technologies co-evolve, robotic surgery has the potential to enhance therapeutic efficacy while simultaneously breaking through the existing cost and dissemination barriers.