Robotic Left Hepatectomy for Perihilar Cholangiocarcinoma.

Background: While robotic liver surgery has been widely established, major liver resection with biliary reconstruction remains challenging.

Methods: A 54-year-old female presenting with painless jaundice was diagnosed with a perihilar cholangiocarcinoma Bismuth IIIb. The indication for resection was confirmed by the multidisciplinary tumor board. We performed a left hepatectomy (H1234-B) with en-bloc resection of the extrahepatic bile duct using the Intuitive Surgical DaVinci Xi system. A tip-up fenestrated grasper, a fenestrated bipolar forceps, and a synchro-seal were used for resection. A 12 mm and a 5 mm laparoscopic trocar were placed for assistance. Hilar lymphadenectomy was performed for the stations 12a, 8a, 9, 7, 12b, and 12p. The clamp-crush-technique was applied for parenchymal dissection and the right hilar plate was dissected with robotic scissors. The caudate lobe was detached from the retrohepatic vena cava and short veins were clipped. The posterolateral and anteromedial bile ducts were reconstructed with two jejunostomies using PDS 5-0 running sutures. Biliary stents (9 French) were placed in each anastomosis. Retrieval of the specimen and a Roux-en-Y- jejunojejunostomy were performed via an umbilical mini-laparotomy.

Results: The operation time was 498 min, the cumulative Pringle time during parenchymal transection was 43min. R0 resection was achieved and 26 lymph nodes were retrieved. The postoperative course was uneventful and the patient was discharged on postoperative day 10.

Discussion: This video supports previous reports demonstrating that the DaVinci Xi surgical system can safely perform even highly complex liver resections with biliary reconstruction. While techniques and strategies in laparoscopic liver surgery have become increasingly harmonized in recent years, there are still major inter-center differences in robotic liver surgery. The video demonstrates in detail each relevant step of a robotic left hepatectomy with biliary reconstruction and highlights our center-specific strategies, techniques, and approaches.