Robotic Resection of Right Perihilar Intrahepatic Cholangiocarcinoma: Practical Technique of Major Hepatic Resection for Biliary Tract Cancer

Introduction

Cholangiocarcinoma is an aggressive hepatobiliary cancer for which curative-intent management frequently requires major hepatic resection with radical regional lymphadenectomy to achieve complete tumor clearance and accurate pathologic staging. Negative margin (R0) resection and adequate lymph node evaluation remain the most important determinants of long-term survival and guide adjuvant therapy.^1,2 Lesions located centrally, adjacent to the hepatic hilum, are technically demanding because safe dissection must be performed in proximity to the portal triad, major hepatic veins, and the biliary confluence.

Contemporary series support the feasibility, safety, and reproducibility of minimally invasive liver resection for selected patients with intrahepatic cholangiocarcinoma, demonstrating comparable oncologic outcomes and improved perioperative recovery relative to open approaches in appropriately selected cohorts.^3-5 However, centrally located tumors requiring major hepatectomy with formal portal lymphadenectomy remain less well represented, and many existing reports emphasize feasibility and outcomes rather than detailed standardized operative technique.^3,4 While robotic liver surgery continues to expand due to improved dexterity, tremor filtration, wristed instrumentation, and stable three-dimensional visualization, standardized descriptions of robotic major hepatectomy combined with systematic portal lymphadenectomy remain limited.

This report is presented within the context of an established robotic hepatobiliary program in which operative strategy, case selection, and perioperative workflow have been progressively refined. Our prior institutional analyses have included a decade-long experience with over 500 robotic hepatectomies, characterization of learning-curve progression, and development of a robotic-specific difficulty scoring system for preoperative complexity assessment.^6-8 In this context, the present video is intended not only to demonstrate feasibility but also to illustrate how these elements converge into a reproducible, structured operative strategy for centrally located intrahepatic cholangiocarcinoma, which is easy for others to learn/adopt.

Methods

A 76-year-old woman with a complex oncological history and background hepatic steatosis was diagnosed with a 5.5-cm centrally located intrahepatic cholangiocarcinoma. Preoperative evaluation included contrast-enhanced CT and MRI to define tumor extent and vascular anatomy, as well as volumetric assessment to confirm an adequate future liver remnant, consistent with contemporary recommendations for safe major hepatectomy.^3,5

Case selection followed a structured institutional framework incorporating tumor location, proximity to major vascular structures, and anticipated technical complexity. These considerations, informed by prior work on robotic hepatectomy learning curves and preoperative difficulty stratification, supported a minimally invasive approach while maintaining oncological intent and outcomes.^7,8 Following multidisciplinary tumor board review, robotic resection was pursued.

Results

The operative sequence reflects a stepwise approach developed through iterative refinements over a decade. After confirming absence of extrahepatic metastasis, a systematic portal dissection was undertaken, with early identification and control of the ipsilateral right hepatic artery and right portal vein. This inflow-first strategy contrasts with parenchymal-first approaches described in some series and facilitates clear demarcation of the transection plane while minimizing blood loss.

Inflow occlusion (Pringle maneuver) was not routinely required, as parenchymal transection was performed under low central venous pressure anesthesia along intersegmental plane, known to have minimal crossing intrahepatic biliovascular structures. Avoidance of routine inflow occlusion reflects evolving evidence supporting low CVP strategies to reduce bleeding while limiting ischemia-reperfusion injury, especially in patients with underlying hepatic parenchymal dysfunctions. ⁵

Parenchymal transection was performed using energy devices with meticulous identification of vascular and biliary structures, avoiding blind placement/insertion of transecting instruments into the deep hepatic parenchyma. The robotic platform provided enhanced visualization and articulation, which is particularly advantageous in centrally located tumors requiring precise dissection adjacent to hilar structures. ⁴

Ultimately the right hepatic vein was divided using a vascular stapler to complete the hepatectomy. A formal portal lymphadenectomy was then completed. This included nodal clearance along the common hepatic artery, proper hepatic artery, portal vein, and retropancreatic region all the way up to the hilar plate, consistent with oncological recommendations by American Joint Committee on Cancer. Current staging guidelines support retrieval of at least six lymph nodes for accurate nodal assessment and prognostication in intrahepatic cholangiocarcinoma.^1,2

The operation was completed robotically in 6 hours with an estimated blood loss of 150 mL. No intraoperative or postoperative complications occurred. The patient was discharged on postoperative day 5. These perioperative outcomes are consistent with contemporary robotic hepatectomy series demonstrating reduced blood loss and shorter hospital stay in selected patients.^3-5

Final pathology demonstrated a poorly differentiated intrahepatic cholangiocarcinoma with negative margins (R0) and no lymph node metastases (0/6). At one-year follow-up, there is no evidence of recurrence.

Discussion

Contemporary literature supports minimally invasive liver resection as a feasible approach for intrahepatic cholangiocarcinoma in selected patients; however, reports focusing on centrally located tumors requiring major hepatectomy with formal lymphadenectomy remain relatively very limited.^3,4 Furthermore, many existing studies emphasize perioperative outcomes rather than defining reproducible operative strategies, which may limit broader adoption, especially for robotic hepatobiliary programs early in their learning curves.

Within this context, the present report reflects a refinement and structured implementation of robotic right hepatectomy rather than early adoption. The operative approach demonstrated here incorporates principles shaped through cumulative experience, with emphasis on consistency in sequencing, oncological adequacy, and technical reproducibility. The primary contribution of this work lies in its instructive value. The stepwise framework, comprising early hilar control, inflow-first sequencing, and standardized portal lymphadenectomy, provides a reproducible approach that may be transferable to other hepatobiliary centers attempting to increase their operative complexities.

The technical sequence of ipsilateral hepatic artery and portal vein ligation, followed by liver transection along the ischemic demarcation line is well demonstrated. The use of indocyanine green by intravenous administration can also further clarify the line of parenchymal transection and aid in the identification of hepatic duct to be ligated at the level of hilar plate once the liver lobes had been divided. Avoiding blind placement of transecting instrument is key to prevent inadvertent major hepatic vein injury, the most frequent cause of unplanned conversion in major hepatectomy. Safe parenchymal transection can be achieved with direct identification of intrahepatic vascular structures using robotic crush-clamp techniques under appropriate dynamic traction-countertraction. Finally, the hepatic vein trunk is isolated intrahepatically and divided using a stapler under direct visualization.

This context supports the generalizability of the approach. Beyond technical execution, the integration of structured preoperative assessment and standardized workflow highlights how minimally invasive major hepatectomy can be implemented in a consistent and reproducible manner.

While a single-case report cannot independently establish a change in standard practice, the present work contributes to a growing body of evidence supporting minimally invasive approaches for complex hepatobiliary malignancies. In this context, the described technique may support the incremental expansion of robotic indications for selected centrally located tumors when performed within structured programs.^3-5

Conclusion

Robotic right hepatectomy with portal lymphadenectomy is a feasible minimally invasive option for selected patients with centrally located intrahepatic cholangiocarcinoma. Beyond feasibility, this report emphasizes a structured, easy-to-learn, and reproducible operative approach informed by cumulative experience in robotic hepatobiliary surgery. The technique presented may serve as a practical framework/guidance for centers seeking to extend minimally invasive strategies to more complex oncological resections while maintaining adherence to established surgical principles.

Supplemental Material