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^3,4. Recent advancements in laparoscopic surgery have increased surgeons' confidence in managing hilar cholangiocarcinoma. Li Jun et al. reported that the application of laparoscopic techniques in the surgical treatment of perihilar cholangiocarcinoma is a safe option^5,6. Studies have suggested that laparoscopic radical resection and robotic surgery are comparable to open radical resection in terms of safety and radicality, and better therapeutic effects can be achieved by selecting appropriate cases^7,8,9. In experienced centres, the resectability rate is as high as 75%¹⁰. Overall, laparoscopic surgery offers several advantages, including a reduced occurrence of complications and a shorter recovery time. However, there are few reports on hilar cholangiocarcinoma with portal vein invasion, and no guidelines or consensus have been formed. In this case, the operation was completed through en bloc resection of the hilar lymph nodes and plexus, continuous suture reconstruction after resection of the invading portal vein, and microplasty of multiple bile duct openings, combined with a Roux-en-Y choledochojejunostomy, all under total laparoscopy. This case offers insights and solutions for the application of laparoscopic radical resection in patients with hilar cholangiocarcinoma and portal vein invasion.

Case presentation
A 69-year-old male was admitted to the hospital due to tea-coloured urine and a loss of appetite for more than 20 days without an obvious cause. A comprehensive abdominal ultrasound examination suggested a possible cholangiocarcinoma. He had taken self-administered medications such as Jinqiancao granules, but the symptoms did not improve significantly. He had a 15-year history of type 2 diabetes, which was controlled with metformin, dapagliflozin, and acarbose. There was no history of infectious diseases or surgeries. Physical examination revealed jaundice of the skin and sclera; no obvious tenderness, rebound tenderness, or muscular tension was found in the abdomen.

Diagnosis, assessment, and plan
Diagnostic assessment revealed elevated Carbohydrate Antigen 19-9 (CA19-9) levels at 146.5 U/mL and Carcinoembryonic Antigen (CEA) levels at 3.5 ng/mL, with liver function classified as Child-Pugh grade B. Preoperative imaging via enhanced upper abdominal computed tomography (CT) and magnetic resonance imaging (MRI) confirmed suspected hilar cholangiocarcinoma with probable vascular invasion and lymph node metastasis (Figure 1). The patient was diagnosed with hilar cholangiocarcinoma. The surgical plan comprised laparoscopic radical resection for hilar cholangiocarcinoma. This involved en bloc resection of hilar lymph nodes and the perineural plexus, followed by segmental portal vein resection with continuous suture anastomosis. The procedure concluded with microsurgical reconstruction of multiple biliary ducts and Roux-en-Y hepaticojejunostomy.

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: Standard preoperative interventions included nasogastric tube placement for gastrointestinal decompression, urinary catheterization, and central venous catheterization. The abdominal operative field was prepared with an antiseptic solution and sterile draping. Ensure the availability of the robotic system and robotic instruments.
2. Trocar Placement: A 10-mm vertical incision was created 1 cm right of the umbilicus using a scalpel, and a 10-mm trocar was inserted as the observation port. The insufflation tube was connected to the a 10 mm trocar to establish pneumoperitoneum (with a pressure of 14 mmHg). Under direct visualization, the following working ports were established:
   1. a 5-mm trocar at the right subcostal point (1 cm inferior to the intersection of the right midclavicular line and costal margin);
   2. a 12-mm trocar at the left subcostal point (1 cm inferior to the intersection of the left midclavicular line and costal margin);
   3. two 12-mm trocars positioned bilaterally in the supraumbilical region (immediately superior to the umbilicus);
      ​NOTE: The surgeon operated from the patient's right side with the assistant positioned contralaterally, and the laparoscope was maintained in the umbilical observation port. It was worth noting that the layout of the trocars and the position of the observation port could be appropriately adjusted according to the location, size, and other conditions of the lesion.

2. Surgical procedure

1. Abdominal exploration: A full abdominal exploration was performed using laparoscopy to observe the shape, size, texture, and other characteristics of the liver, gallbladder, and common bile duct, and assess for the presence of intra-abdominal metastatic lesions. No ascites or omental adhesions were observed.
   ​NOTE: The liver exhibited cholestatic changes without evidence of masses. The gallbladder measured approximately 6 × 4 × 3 cm in size, and the common bile duct had a diameter of approximately 0.8 cm. The stomach, small intestine, and large intestine appeared unremarkable.
2. Cholecystectomy: An electrocoagulation hook was used to dissect the adhesions between the gallbladder and the greater omentum to expose the gallbladder. Calot's triangle was carefully dissected to isolate the cystic artery and cystic duct.
   1. Absorbable ligating clips were applied to both the proximal and distal ends of these structures, which were then transected using curved scissors. The gallbladder was subsequently removed from the gallbladder fossa via a combined antegrade and retrograde approach.
      NOTE: The Calot's triangle is constituted by the common hepatic duct, cystic duct, and cystic artery.
3. En-bloc dissection of the hilar lymph nodes and nerve plexuses: An ultrasonic scalpel was used to dissect, mobilize, and suspend the portal vein (PV). The extrahepatic bile duct and lymph node groups 8, 12, 12p, and 13 en bloc were removed along the PV towards the hepatic hilum, achieving skeletonization of the hepatoduodenal ligament (Figure 2).
4. Dissection of the first hepatic hilum and portal vein reconstruction: The tumour was found to be slightly adherent to the right hepatic artery, with invasion of the left branch of the portal vein. The main portal vein and its right branch were clamped, followed by sharp transection of the left portal vein, which was then repaired (Figure 3).
5. Biliary tract biopsy: The inferior margin of the common bile duct was transected, and an intraoperative frozen section examination was performed on the stump, with no tumour growth observed at the resection margin. The right hepatic duct was transected up to the right anterior hepatic duct and right posterior hepatic duct, ensuring that the intraoperative frozen section results of the resection margins were negative. The hilar bile ducts were shaped (Figure 4).
6. Caudate lobectomy combined with left hemihepatectomy: The left hemiliver was mobilized by dividing the falciform, left triangular, and left coronary ligaments. Following skeletonization of the hepatoduodenal ligament, the left hepatic artery and left portal vein were ligated and divided, achieving devascularization of the left hemiliver (including the caudate lobe) with clear demarcation.
   1. Parenchymal transection was performed along the predefined plane using an ultrasonic scalpel until reaching the second hepatic hilum. The left hepatic vein was then divided with a blue cartridge stapler, and the left hemiliver, along with the caudate lobe, was completely removed (Figure 5).
7. Microplasty of multiple bile duct orifices combined with Roux-en-Y biliary-enteric anastomosis: After the hilar bile ducts were shaped, the jejunum was transected using a stapler (one white load). The distal end was anastomosed to the lateral wall of the bile duct via a side-to-side biliary-enteric anastomosis anterior to the colon.
   1. At a distance of 50 cm from the biliary-enteric anastomosis, an enter-enteric anastomosis was performed using a stapler (one white load). The seromuscular layer was sutured with a barbed suture (Figure 6).
8. Drain placement: After haemostasis was achieved with an ablation electrode, a total of 3 drainage tubes were placed at Winslow's foramen and the left hepatic transection surface.
9. Postoperative care
   1. ERAS postoperative management: Early oral intake and early ambulation were implemented to promote the recovery of gastrointestinal function and physical rehabilitation, thereby reducing postoperative complications and improving patients' quality of life.
   2. Nutritional support: Measures were taken to facilitate gastrointestinal recovery, and a multidisciplinary consultation was conducted to formulate an individualized treatment plan.
   3. Prevention and treatment of complications: Dynamic monitoring of bilirubin, albumin, and haemoglobin; biochemical analysis of drainage fluid; and bacterial culture were performed.

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