Robotic Klatskin Type 3A Resection with Biliary Reconstruction: Description of Surgical Technique and Outcomes of Initial Series.

INTRODUCTION: Minimally invasive resection for perihilar cholangiocarcinoma is an emerging technique that requires both mastery in minimally invasive liver resection and biliary reconstruction. Due to technical difficulties in biliovascular dissection, radical portal lymphadenectomy and the need for fine suturing during bilioenteric anastomosis, this type of resection is generally not performed laparoscopically, even at high-volume, liver-surgery centers.1-3 In modern literature, a detailed, operative description of robotic technique for this operation with outcome data is lacking. This video article demonstrates a pure robotic Klatskin Type 3A resection with clinical outcomes of our initial series.

VIDEO: A 77-year-old man presented with jaundice and findings of bilateral, intrahepatic, ductal dilation (Right > Left). Radiological imaging showed a type 3A Klatskin tumor with associated thrombosis of the right, anterior portal vein. A further endoscopic evaluation with cholangioscopy confirmed a high-grade Bismuth 3A biliary malignant stricture. Endoscopic drainage was achieved with placement of two, 7-French, 15-cm, plastic, endobiliary stents. A 3-D anatomical liver reconstruction showed a 2-cm mass located in the area of right, anterior, sectoral, Glissonean pedicle with standardized, future, liver-remnant (left hepatic lobe) volume of 50%. The patient was placed supine on the operating table. General endotracheal anesthesia was administered. After exclusion of metastatic peritoneal disease with diagnostic laparoscopy, cholecystectomy and systematic radical portal lymphadenectomy were first completed with a goal to obtain more than six lymph nodes. After appropriate portal lymphadenectomy, the common bile duct was isolated and transected at the level of pancreatic head. The plastic, endobiliary stents were removed, and a distal common bile duct margin was sent for a frozen-section examination to rule out distal extension of the cholangiocarcinoma. A small, accessory, right, hepatic artery lateral to the main portal vein was ligated with locking clips and removed together with the adjacent nodes and lymphatic bearing tissues. The intrapancreatic portion of the distal common bile duct was suture closed once the distal common bile duct margin was confirmed to be negative for neoplasia by the frozen-section examination. The proximal bile-duct dissection commenced cephalad toward the hilar bifurcation. Once the biliary bifurcation has been adequately dissected and detached from the hilar plate, the distal, left, hepatic duct was then transected near the base of the umbilical fissure to gain an R-0 resection margin. A second frozen-section specimen was obtained from the left, hepatic duct cut edge to ensure an absence of infiltrating tumor cells on the future, bile-duct remnant side. Division of short, hepatic veins off the inferior vena cava (IVC) were next completed. Once the line of hepatic-parenchymal transection was confirmed by using indocyanine green administration, the right hepatic artery and portal vein were ligated and clipped. The liver, parenchymal transection began with a crush-clamp technique utilizing robotic, fenestrated bipolar forceps and a vessel-sealing device. Preservation of the middle hepatic vein is always the preferred technique to avoid congestion of the left medial sector of the liver. The entire right hepatic lobe and the caudate lobe were removed en bloc. A large, Makuuchi ligament was isolated and divided by using a robotic, vascular-load stapler once the liver is open-booked. Finally, the root of the right hepatic vein was exposed and transected flush to the IVC by using another load of robotic vascular stapler. The biliary reconstruction then began by creating a 60-cm, roux limb for a hepaticojejunostomy bilioenteric anastomosis. A side-to-side, stapled jejunojejunostomy was created by using two applications for robotic 45-mm, blue load staplers. The common enterotomy was closed with running barbed sutures. The roux limb was then transposed retrocolically toward the porta hepatis. A single end-to-side hepaticojejunostomy anastomosis was created with running absorbable 4-0 barbed sutures. Finally, a closed suction abdominal drain was placed before closing.

RESULTS: The operative time was approximately 8 hours with 150 ml of blood loss. The postoperative course was unremarkable. The final pathology report confirmed a moderately differentiated perihilar cholangiocarcinoma with negative resection margins. Ten lymph nodes were harvested. No nodal metastasis or lymphovascular invasion was found. Since 2021, we have undertaken robotic resection of Klatskin 3A tumor in four patients with a median age of 70 years. All patients presented with jaundice, and they mainly underwent preoperative biliary drainage using ERCP. The median operative duration was 508 minutes with estimated blood loss of 150 ml. R-0 resection margins were obtained in all patients. One patient suffered from postoperative complications requiring treatment of line sepsis using intravenous antibiotics. We did not find a 90-day mortality in this series. At a median follow-up period of 15 months, all of the patients were alive without any evidence of disease recurrence.

CONCLUSIONS: Robotic resection of Type 3A Klatskin tumor is safe and feasible with appropriate experience in robotic hepatobiliary surgery, as demonstrated in this video article.