Robotic-Assisted Radical Resection for Hilar Cholangiocarcinoma

Summary

This article primarily introduces a surgical approach that leverages the advantages of robotic assistance to perform precise radical resection of hilar cholangiocarcinoma, surrounding lymph node dissection, and biliary-enteric anastomosis. This represents a significant definitive surgical therapy for early-stage hilar cholangiocarcinoma.

Abstract

Radical resection for hilar cholangiocarcinoma is particularly challenging due to complex anatomy and high operative risks. While conventional laparoscopic surgery has been used with reported R0 resection rates of 86.3%, it is limited in precision and complex vascular or biliary reconstruction. Robotic-assisted surgery overcomes these constraints through three-dimensional visualization, enhanced instrument maneuverability, and tremor filtration. This approach is associated with reduced intraoperative blood loss compared to laparoscopic and open techniques and demonstrates superior capability in complex reconstructions. Its refined suturing techniques shorten anastomosis time and reduce the risk of postoperative bile leakage. This article details the technique of utilizing robotic assistance for the precise radical resection of hilar cholangiocarcinoma. This approach fully capitalizes on the robotic advantages to achieve more thorough lymphadenectomies, precise assessment of vascular invasion, and more efficient biliary-enteric anastomosis. This approach represents a feasible and safe option for Bismuth type I hilar cholangiocarcinoma, pending validation through larger studies.

Introduction

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.

Protocol

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.

Results

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.

Discussion

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 stru...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Grasping forceps	Shenzhen Jingfeng MEDICAL Technology Co., Ltd.	MP1305	Used for tissue exposure, traction, dissection, and separation during surgery
Laparoscope	Shenzhen Jingfeng MEDICAL Technology Co., Ltd.	MP2000	Used for intra-operative visualization
Monopolar Hook	Shenzhen Jingfeng MEDICAL Technology Co., Ltd.	MP1314	Used for precise tissue dissection, stripping, hooking/dividing, coagulation, and fulguration
Monopolar scissors	Shenzhen Jingfeng MEDICAL Technology Co., Ltd.	MP1311	Used for surgical dissection, separation, and hemostasis of tissues
Shenzhen Jingfeng Medical surgical robotic system	Shenzhen Jingfeng MEDICAL Technology Co., Ltd.	MP2000	Support the operation of the surgery
The single-use ultrasonic scalpel	Shenzhen Jingfeng MEDICAL Technology Co., Ltd.	MP1500	Used for the safe transection of highly vascularized tissues and precise dissection and separation