Robotic approach for perihilar cholangiocarcinoma: from Bismuth 1 to vascular resection

Robotic Resection of Left Intraductal Papillary Cholangiocarcinoma with Roux-en-Y Hepaticojejunostomy: Standardized Technique of Liver Resection with Biliary Reconstruction

BACKGROUND

Intraductal papillary cholangiocarcinoma is a preinvasive type of biliary tract cancer with a relatively favorable prognosis, requiring complete resection of the involved bile ducts and corresponding liver segments (Christodoulou et al. in J Gastrointest Surg, 2024; Sucandy et al. in Collab Study Ann Surg Oncol 31:81-89, 2024; Magistri et al. in Eur J Surg Oncol 49:107002, 2023; Sucandy et al. in Ann Surg Oncol 30:8559-8560, 2023). When located in the perihilar region, mild cholangitis and segmental or lobular biliary obstruction are often the presenting findings. Herein, we demonstrate our technique for robotic resection of intraductal cholangiocarcinoma with biliary reconstruction and portal lymphadenectomy.

PATIENTS AND METHODS

A 78-year-old woman presented with recurrent fever and left hepatic duct filling defects with ipsilateral biliary dilation, concerning for intraductal cholangiocarcinoma. Computed tomography (CT) and magnetic resonance imaging (MRI) indicated a lesion within the left hepatic duct involving biliary bifurcation. After the portal lymphadenectomy, the distal common bile duct was transected with scissors. A choledochoscope was inserted into the proximal extrahepatic duct to visualize the tumor location and extent. After obtaining inflow control, the anatomical left hepatectomy was undertaken with caudate resection. An ultrasonic dissector was used for parenchymal transection. Once the specimen was removed, a retrocolic Roux-en-Y-hepaticojejunostomy was fashioned to the right anterior, right posterior, and accessory right dorsal hepatic duct as a single anastomosis following unification ductoplasty technique. We did not feel the need to place biliary stents owing to the relatively large composite size of the bile ducts after ductoplasty (more than 1 cm in total). The caudate lobe biliary branch was about 6-7 mm in size, which is an acceptable diameter in our practice to perform a robotic anastomosis without placing a biliary ductal stent.

RESULTS

The operation was completed uneventfully with 50 ml of blood loss. After an uncomplicated recovery, she was discharged home on postoperative day six. She is currently two years post-resection without recurrent disease.

DISCUSSION

The level of proximal bile duct transection is determined by a combination of detailed preoperative radiological evaluation (using MRI/MRCP/CT scan) and intraoperative clinical investigation using choledoschope/Spyglass biliary endoscope. The lumen of the bile duct is endoscopically visualized using Spyglass to determine proximal end of tumor involvement. Once this is endoscopically visualized, robotic camera is then directed and focused to search transilluminating light originated from the end of the Spyglass. Gentle external tapping on the proximal bile duct wall using robotic scissors is applied to confirm the transection level while observing the endoscopic view at all time. After each transection of the bile duct, cut ends (bile duct stumps/margins) were evaluated and confirmed to be negative through intraoperative frozen section pathological examination, as the oncological primary goals.

CONCLUSIONS

Robotic resection of intraductal cholangiocarcinoma with biliary reconstruction and portal lymphadenectomy is safe and feasible with excellent outcomes. We believe this approach will become an alternative to the conventional open operation.

Robotic surgery for perihilar cholangiocarcinoma: a concise systematic review

BACKGROUND

Perihilar cholangiocarcinoma (PHC) is a challenging malignancy with a poor prognosis, and the role of robotic surgery in its management remains debated. This systematic review aims to assess the feasibility of robotic surgery for PHC.

METHODS

A systematic literature search was conducted following PRISMA guidelines in Medline, Cochrane Library, and Web of Science for English-language studies on robotic surgery for PHC between 2000 and 2024.

RESULTS

Of the initial 405 manuscripts identified, five studies comprising 110 patients met the inclusion criteria. Pooled analysis showed that operative time ranged from 276 (170-500) to 840 (770-890) minutes, with intraoperative blood loss between 125 (50-425) and 700 (600-800) ml. The rates of overall and major morbidity were 50.0% and 13.6%, respectively. The 30-day and 90-day postoperative mortality rates were 1.8% and 1.9%, respectively. R0 resections were achieved in 78.2% of patients, with a median lymph node retrieval of 7 (8 ± 6.6) to 11 (6-31). Follow-up duration ranged from 7.5 (8.3 ± 2.3) to 15 (19 ± 16) months, recurrence was observed in 14.3% (6/42) of patients.

CONCLUSIONS

Robotic surgery for PHC demonstrates promising perioperative outcomes; however, further studies are needed to assess its long-term oncological efficacy compared with traditional approaches.

Is robotic liver resection feasible in patients with lesions in close proximity to major vessels? A propensity score matching analysis

INTRODUCTION

Robotic surgery is widely diffused in the surgical field and is becoming increasingly prevalent, however several aspects need more detailed assessment. One of them concerns the role of robotic liver surgery for lesions in contact with major vascular (CMV) pedicles. The aim of our study is to evaluate and compare intra and post operative outcomes in patients undergoing robotic liver resections between lesions in contact or free from major vessels.

METHODS

A multicentric retrospective study was performed including 1030 patients who underwent robotic liver resection. Patients were divided into two groups according to vascular contact. Intra and post-operative outcomes were compared between the groups before and after Propensity Score Matching.

RESULTS

After propensity score matching 889 patients were included in the study. Among these lesions, 595 were not in contact with major vessels (NCMV) and 294 were in contact with major vessels (CMV). Use of Pringle Manoeuvre was more associated with CMV resections (49.8 % vs 31.2 %, p = 0,0001). No differences in terms of operative time, conversion rate, morbidity and type of complications were observed after PSM.

CONCLUSION

The presents study shows how robotic surgery is a valid and safe technique also for resection of tumors close to vascular pedicles.

Essential updates 2022/2023: A review of current topics in robotic hepatectomy

The liver requires careful handling intra-operatively owing to its vital functions and complexity. Traditional open hepatectomy, while standard, is invasive and requires long recovery periods. Laparoscopic hepatectomy is a less invasive option, with its own challenges. The rise of robotic surgery, such as the da Vinci® system, improves precision and control, addressing the limitations of conventional methods, but brings new concerns, such as costs and training. This review focuses on the latest advancements in robotic hepatectomy from 2022/23 articles, delving into topics like "robotic surgery in liver transplantation," "robotic hepatectomy for hilar cholangiocarcinoma," "robotic vascular reconstruction following hepatectomy," "robotic repeat hepatectomy," and "prospective trials in robotic hepatectomy." To retrieve articles, a focused literature search was conducted using PubMed for articles from 2022/23 with a 5-year filter, excluding reviews. Initially, abstracts were screened, and relevant articles on robotic surgery were examined in full for inclusion in this review. Although all the above items are cutting-edge, and many of the references are necessarily at the level of case reports, recent articles are still accompanied by surgical videos, which are useful to readers, especially surgeons who are considering imitating the procedures. In summary, we examined the recent advancements in robotic liver resection. The inclusion of videos that present new techniques aids in knowledge transfer. We anticipate the continued growth of this field of research.

Laparoscopic versus open liver resection for colorectal liver metastasis: an umbrella review

INTRODUCTION

This study comprehensively compared laparoscopic liver resection (LLR) to open liver resection (OLR) in treating colorectal cancer liver metastasis (CRLM).

METHODS

A systematic review of relevant literature was conducted to assess a range of crucial surgical and oncological outcomes.

RESULTS

Findings indicate that minimally invasive surgery (MIS) did not significantly prolong the duration of surgery compared to open liver resection and notably demonstrated lower blood transfusion rates and reduced intraoperative blood loss. While some studies favored MIS for its lower complication rates, others did not establish a statistically significant difference. One study identified a lower post-operative mortality rate in the MIS group. Furthermore, MIS consistently correlated with shorter hospital stays, indicative of expedited post-operative recovery. Concerning oncological outcomes, while certain meta-analyses reported a lower rate of cancer recurrence in the MIS group, others found no significant disparity. Overall survival and disease-free survival remained comparable between the MIS and open liver resection groups.

CONCLUSION

The analysis emphasizes the potential advantages of LLR in terms of surgical outcomes and aligns with existing literature findings in this field.

SYSTEMATIC REVIEW REGISTRATION

[website], identifier [registration number].

Initial clinical outcomes of robotic resection for perihilar cholangiocarcinoma: Is it safe and effective?

BACKGROUND AND OBJECTIVES

We aimed to describe our outcomes of robotic resection for perihilar cholangiocarcinoma, the largest single institutional series in the Western hemisphere to date.

METHODS

Between 2016 and 2022, we prospectively followed all patients who underwent robotic resection for perihilar cholangiocarcinoma.

RESULTS

In total, 23 patients underwent robotic resection for perihilar cholangiocarcinoma, 18 receiving concomitant hepatectomy. The median age was 73 years. Operative time was 470 min with an estimated blood loss of 150 mL. No intraoperative conversions to open or other intraoperative complications occurred. Median length of stay was 5 days. Four postoperative complications occurred. Three readmissions occurred within 30 days with one 90-day mortality. R0 resection was achieved in 87% of patients and R1 in 13% of patients. At a median follow-up of 27 months, 15 patients were alive without evidence of disease, two patients with local recurrence at 1 year, and six were deceased.

CONCLUSIONS

Utilization of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with excellent perioperative outcomes. Further studies are needed to determine the long-term oncological outcomes.

Robotic ALPPS for primary and metastatic liver tumours: short-term outcomes versus open approach

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is one of the strategies available for patients initially unresectable. High risk of peri-operative morbidity and mortality limited its application and diffusion. We aimed to analyse short-term outcomes of robotic ALPPS versus open approach, to assess safety and reproducibility of this technique. A retrospective analysis of prospectively maintained databases at University of Modena and Reggio Emilia on patients that underwent ALPPS between January 2015 and September 2022 was conducted. The main aim of the study was to evaluate safety and feasibility of robotic approach, either full robotic or only first-stage robotic, compared to a control group of patients who underwent open ALPPS in the same Institution. 23 patients were included. Nine patients received a full open ALPPS (O-ALPPS), 7 received a full robotic ALPPS (R-ALPPS), and 7 underwent a robotic approach for stage 1, followed by an open approach for stage 2 (R + O-ALPPS). PHLF grade B-C after stage 1 was 0% in all groups, rising to 58% in the R + O-ALPPS group after stage 2 and remaining 0% in the R-ALPPS group. 86% of R-ALPPS cases were discharged from the hospital between stages 1 and 2, and median total in-hospital stay and ICU stay favoured full robotic approach as well. This contemporary study represents the largest series of robotic ALPPS, showing potential advantages from full robotic ALPPS over open approach, resulting in reduced hospital stay and complications and lower incidence of 90-day mortality.