Robotic Systematic Portal Lymphadenectomy. Description of Surgical Technique

Gallbladder cancer is a relatively uncommon but highly malignant hepatobiliary cancer with incidence of less than 20 000 cases annually in the United States. ¹ Central liver resection removing part of segment 4/5 together with radical portal lymphadenectomy in the standard surgical treatment for this disease. A recent Americas Hepatopancreatobiliary Association (AHPBA) and American Joint Committee on Cancer (AJCC) guideline requires removal of at least 6 portal lymphnodes to be considered oncologically adequate. ² The anatomical variation and complexity of structures within the hepatoduodenal ligament create a technical challenge in performing this operative step. Many surgeons are struggling to obtain the minimum lymphnode count, especially in the era of minimally invasive surgery. Others are afraid of dissecting the lymphnodes dorsal to the portal vein due to difficult access and fear of bleeding. A clear anatomical understanding is crucial in order to avoid inadvertent injuries to the hepatic inflow and the bile duct. In this article, we demonstrate our standardized approach to the systematic portal lymphadenectomy using a robotic platform.

A 71-year-old woman presented with a 4.3 cm gallbladder fundal mass consistent with gallbladder cancer without hepatic invasion. Her past medical history was consistent with hyperlipidemia, hypertension, and treated chronic lymphocytic leukemia. A robotic radical cholecystectomy with partial segment 4/5 liver resection and systematic portal lymphadenectomy was planned. On further metastatic workups, we did not see any evidence of distant metastasis. For the purpose on this study, we focus the video demonstration and discussion on the technique of robotic portal lymphadenectomy

The abdominal cavity was carefully entered and thoroughly inspected. The Tokyo classification for lymphnode stations was shown in the video. The radical systematic portal lymphadenectomy began with opening the gastrohepatic ligament using a robotic monopolar scissor cautery and fenestrated bipolar forceps. The lymphadenectomy then continues toward the celiac axis and common hepatic artery using a hook electrocautery. The assistant surgery is using a laparoscopic suction device to help with exposure and suctioning. Next, the lymphnodes along the left hepatic artery toward the base on the umbilical fissure was removed. It is important to avoid any inadvertent injury, especially the invisible thermal damage to the biliovascular structures from the energy devices. The periportal lymphnode was then removed with a hook cautery. Each of the nodes were labeled individually according to their stations. We then moved toward the lateral aspect of the common bile duct by carefully dissecting the lymphatic bearing tissues covering the anterior aspect of the porta hepatis. The station 12B node was then dissected and removed using a vessel sealer in a hemostatis fashion after a partial kocher maneuver to facilitate safe access. Identifiable lymphatic channels were clipped to avoid lymphatic leak and to minimize chance to develop postoperative ascites. In a case of gallbladder cancer, the cystic duct was transected as it enters the common bile duct. A cystic duct margin was sent for a frozen section examination to exclude presence of carcinoma. Finally, the retroportal lymphnode is removed and sent to the pathology department for an examination.

The total operative duration was approximately 2 hours with minimal blood loss. The patient made an uneventful recovery. The final pathology report confirmed pT1bN0M0 well differentiated gallbladder adenocarcinoma. 18 porta hepatic lymphnodes were retrieved without evidence of tumor infiltration. At 6 month follow-up, the patient is doing well with no evidence of recurrent disease.

In a recent study by Ratti et al, the issue of robotic vs laparoscopic and open lymphadenectomy was discussed.^3,4 In their study, 25 robotic resections with portal lymphadenectomy from a single center institution were included and matched by inverse probability treatment weighting with 97 laparoscopic and 113 open procedures. An analysis was performed comparing the characteristics and outcomes of the robotic vs laparoscopic portal lymphadenectomy. They found that minimally invasive techniques performed equally well regarding the number of harvested nodes, blood transfusions, functional recovery, length of stay, and major morbidity and provided a short-term benefit to patients when compared with the open technique. A better performance of the robotic approach over laparoscopic approach (and both approaches over the open technique) was recorded for patients achieving >6 nodes. The robotic surgery performed better than laparoscopic surgery. The authors concluded that minvasive techniques are excellent tools for the management of lymphnodes in patients with biliary tumors, showing feasibility, and oncological adequacy. Robotics could contribute to the large-scale diffusion of these procedures with a high profile of complexity.

In conclusion, the robotic systematic portal lymphadenectomy for biliary tumors as demonstrated in the video provides an alternative technique to achieve adequate oncological outcomes as in the traditional open surgery. This technique should be part of practicing surgeon’s armamentarium in minimally invasive cancer surgery.