Robotic Resection of Type 2 Klatskin’s Tumor With Portal Vein Lateral Venorrhaphy and Dual Hepaticojejunostomy Biliary Reconstruction

Introduction

Perihilar cholangiocarcinoma, commonly known as Klatskin’s tumor, is a technically challenging malignancy to treat due to its proximity to the portal vein (PV) and hepatic artery within the hepatic hilum.^1-4 High probability for R1 resection due to vascular invasion, subsequent local recurrence, and poor oncologic outcomes have historically been major concerns in the surgical management of these tumors.

Current operative management of Bismuth type I and II perihilar cholangiocarcinoma remains an area of ongoing debate. There have been no randomized studies or large multicenter propensity-score matched studies that have addressed this topic specifically to date. While concomitant hepatectomy is commonly performed to maximize the likelihood of R0 resection, several contemporary series have demonstrated that selected Bismuth I and II lesions may be appropriately managed with bile duct resection alone when longitudinal tumor extension into the hepatic ducts and vascular invasion are limited.^5-7 Current NCCN recommendations emphasize the importance of margin-negative resection, vascular assessment, and individualized operative planning based on tumor extent and biliary involvement.^8,9

While traditionally undertaken through an open approach, robotic surgery has emerged as an important minimally invasive platform for selected hilar resections due to enhanced dexterity, three-dimensional visualization, and improved precision during portal dissection and biliary reconstruction.^10,11 Recent robotic hepatopancreatobiliary literature has expanded beyond simple feasibility reports to include increasingly complex hilar dissections, vascular reconstructions, and multiple bilioenteric anastomoses. However, reports specifically focusing on robotic management strategies for selected Bismuth type II lesions requiring portal vein venorrhaphy without major hepatectomy remain limited. While portal vein lateral venorrhaphy is becoming increasingly commonplace during robotic pancreaticoduodenectomy, its application during robotic hilar resection remains less frequently described despite its importance in managing tumor-vessel contact while preserving portal vein continuity. Demonstration of this technique may help improve technical proficiency in robotic vascular handling and expand minimally invasive management of complex hilar pathology without necessarily requiring conversion to an open operation. Furthermore, bile duct resection without concomitant major or extended hepatectomy remains an acceptable strategy in carefully selected patients without significant hilar plate involvement, particularly among elderly patients with substantial medical comorbidities, as is commonly encountered in the Klatskin tumor population.

Additionally, portal vein involvement in perihilar cholangiocarcinoma introduces further technical and oncologic considerations regarding the need for lateral venorrhaphy vs segmental portal vein resection and reconstruction. Preservation of portal vein continuity while maintaining oncologic adequacy may reduce operative morbidity in carefully selected patients. ¹²

Herein, we describe our technical approach for robotic Bismuth type II Klatskin tumor resection requiring portal vein lateral venorrhaphy and dual hepaticojejunostomy reconstruction, with particular emphasis on operative decision-making, margin assessment, portal vein preservation strategy, and complex hilar reconstruction sequencing. Dual hepaticojejunostomy reconstruction is infrequently reported in the robotic literature due to its perceived technical complexity. Detailed technical description of bilateral biliary reconstruction may therefore provide important educational value by demonstrating that dual hepaticojejunostomy can be reproducibly performed by experienced robotic hepatobiliary surgeons without mandatory conversion to an open approach.

Methods

A 72-year-old man presented with obstructive jaundice and a mid-bile duct stricture consistent with Bismuth type II perihilar cholangiocarcinoma. After an appropriate preoperative workup and medical prehabilitation to improve his marginal performance status, a robotic resection was planned as an extrahepatic biliary resection, radical lymphadenectomy, and Roux-en-Y hepaticojejunostomy, securing R0 resection margins.

Preoperative cross-sectional imaging and cholangiographic assessment demonstrated tumor involvement confined to the biliary confluence under the hilar plate without substantial longitudinal extension into the secondary intrahepatic ducts or radiographic evidence of major hepatic vascular encasement. Based on these findings, bile duct resection without formal hepatectomy was selected in order to preserve functioning hepatic parenchyma and thus maximizing safety, while still maintaining oncologic adequacy. Intraoperatively, proximal and distal bile duct margins were carefully assessed to confirm resectability and determine the extent of biliary excision required to achieve/ensure negative margins.

Tumor adherence to the lateral wall of the portal vein was encountered without circumferential vascular involvement (less than 50% of circumferential diameter of the portal vein), allowing portal vein preservation with robotic lateral venorrhaphy rather than segmental portal vein resection and/or interposition graft reconstruction.

Following completion of tumor extirpation and portal vein repair, reconstruction proceeded with unification ductoplasty between the right anterior and posterior sectoral ducts to optimize biliary drainage and to reduce the total number of bilioenteric anastomoses. The number of anastomosis is a well-known factor for postoperative morbidities, specifically anastomotic leak and strictures.

Dual hepaticojejunostomy reconstruction was then completed in a sequential fashion using Roux-en-Y reconstruction.

Results

Robotic perihilar cholangiocarcinoma resection was completed uneventfully, requiring intraoperative portal vein lateral venorrhaphy due to tumor-vessel contact. Main portal vein cross-clamping time was 10 minutes. Unification ductoplasty technique between the right anterior and right posterior sectoral bile ducts was applied, and dual hepaticojejunostomies were required for biliary reconstruction. Negative proximal and distal ductal margins were confirmed intraoperatively using frozen section examinations and on final pathology. At 2-year surveillance follow-up, the patient was doing well without evidence of tumor recurrence.

Conclusions

This case specifically demonstrates the technical feasibility of robotic portal vein lateral venorrhaphy and complex dual hepaticojejunostomy reconstruction during resection of selected Bismuth type II perihilar cholangiocarcinoma.

Rather than broadly establishing superiority of a robotic approach, this report highlights specific technical considerations relevant to robotic perihilar cholangiocarcinoma surgery, including operative selection for bile duct resection without hepatectomy, portal vein preservation strategies while ensuring oncological radicality, and reconstruction of multiple biliary orifices following hilar resection without having to convert to the traditional open method.

Robotic surgery may serve as a useful minimally invasive alternative platform in carefully selected patients requiring complex hilar dissection and reconstruction when performed in experienced hepatopancreatobiliary centers.

Supplemental Material