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

This case study presents a laparoscopic radical resection for Bismuth-Corlette type IIIb perihilar cholangiocarcinoma. A rare feature in this case was the severe adhesion between the tumor and major hepatic arteries, significantly complicating vascular dissection. After the ultrasound-guided peritoneal incision and lymph node dissection, the lesser omentum sac was opened and the gastroduodenal artery, common hepatic artery, and left gastric vein were identified and incised.

The proper hepatic artery could not be dissected due to adhesion to the surrounding tumor tissue. The isolation and suspension of the gastroduodenal artery were continued. The proper hepatic artery was discovered and blunt dissection was not feasible due to tumor adhesion to the right hepatic artery.

Careful sharp dissection was attempted with scissors, though it remained difficult. Adhesions were submitted for intraoperative frozen pathology, which showed inflammatory tissue. While dissecting the right hepatic artery, it ruptured and was repaired using 5-0 vascular sutures.

After confirming good blood flow with ultrasound, dissection was continued until the right hepatic artery was completely freed. Then the left hepatic artery was isolated, ligated using 7-0 silk and vascular clips, and then divided with scissors. Next, the left portal vein was dissected continuously and tumor invasion was identified.

The root of the left portal vein was ligated with a 7-0 silk suture. Afterward, the middle hepatic vein was identified and the segment 4b vein was ligated and divided. The left and right hepatic ducts were exposed and tumor involvement of the biliary confluence and left hepatic duct was found.

The right hepatic duct was transected approximately 0.5 centimeters from the tumor margin along with the bile duct at the caudate lobe. The caudate lobe liver parenchyma was transected followed by ligation and division of the corresponding short hepatic veins and ligamentous attachments. The left hepatic vein was isolated and divided using a stapler.

A complete left hemihepatectomy and caudate lobectomy were performed, fully exposing the middle hepatic vein and inferior vena cava. Finally, the liver transection surface and abdominal cavity were irrigated using warm saline and hemostasis was achieved with bipolar cautery. Lymph node stations 12, 13, 8, 7, 9, 3, and 1 were dissected, completing the left hemihepatectomy with caudate lobectomy.

The patient successfully underwent laparoscopic left hemihepatectomy with caudate lobe resection, regional lymph adenectomy, and Roux-en-Y hepaticojejunostomy. The total operation time was approximately 480 minutes with an estimated blood loss of 300 milliliters. Histopathological analysis of paraffin embedded tissue sections confirmed a well-differentiated intrahepatic cholangiocarcinoma with perineural invasion with no evidence of vascular tumor thrombus and negative margins at all resection sites.

At the 12-month follow-up, contrast enhanced computed tomography scans demonstrated the successful removal of the tumor without significant recurrence or metastasis. Severe vascular adhesions were encountered during the procedure and managed through meticulous dissection and careful vascular preservation. This case highlights that complex perihilar cholangiocarcinoma can be safely treated laparoscopically in selected patients.

The patient recovered well postoperatively without major complications and achieved an R0 resection.