Laparoscopic Resection of Hilar Cholangiocarcinoma

Abstract

Background:

Hilar cholangiocarcinoma is the most common malignant neoplasm of the biliary tract. Surgical resection is the only curative modality of treatment. Liver resection combined with complete extrahepatic bile duct resection, lymphadenectomy, and biliary reconstruction represents the current standard surgical treatment. Laparoscopic liver resection is feasible, safe, and has been extensively used during the last decade. However, technical limitations have limited the adoption of minimally invasive techniques for the treatment of hilar cholangiocarcinoma. This video shows a laparoscopic left hepatectomy with lymphadenectomy and resection of extrahepatic bile ducts. Biliary reconstruction was performed using the hybrid method.

Patient and Method:

A 43-year-old female left-sided hilar cholangiocarcinoma was referred for surgical treatment. The decision was to perform a left hepatectomy with lymphadenectomy and resection of extrahepatic bile ducts. The patient is placed in a supine position with the surgeon standing between the patient's legs. This technique uses five trocars. Pneumoperitoneum is established at a pressure of 12 mm Hg. At laparoscopy, left liver atrophy is evident. First step is to fully mobilize the left liver. A laparoscopic 5-mm snake liver retractor is introduced by the epigastric port and it is used for upward liver retraction and exposure of the hepatic hilum. Extensive hilar lymphadenectomy is performed. Dissection of hepatic hilum is carefully performed exposing the anterior surface of the common bile duct, the common hepatic artery, and the portal vein. The hepatic artery is dissected and encircled. The same maneuver is done with the common bile duct. The left hepatic artery is identified and divided. Hepatic hilum is completed skeletonized. The common bile duct is then divided. Cholecystectomy is performed and the gallbladder is en bloc removed with right-sided lymph nodes. The left portal vein is carefully dissected and ligated. Hepatic pedicle dissection is completed and the left liver is now ischemic and ready to be transected. Future line of transection is marked with cautery, along the liver surface. Liver transection is accomplished with a harmonic scalpel and an endoscopic stapling device as appropriate. Bile ducts from the anterior and posterior right sectors of the liver are identified and measured about 2 mm. Due to the difficult localization and small caliber of the bile ducts, hepaticojejunostomy was performed assisted with the magnification of the 30-degree laparoscope. Pneumoperitoneum is re-established and liver raw surfaces were reviewed for bleeding and bile leaks.

Results:

Operative time was 300 minutes with minimum blood loss. Anastomosis was satisfactorily performed, and the patient did not present any biliary leakage or stenosis during the late follow-up. Recovery was uneventful and patient was discharged on the seventh postoperative day. Histological examination revealed a well-differentiated cholangiocarcinoma with negative lymph nodes and clear surgical margins. The patient was well with no signs of the disease 18 months after the procedure.

Conclusion:

Laparoscopic left hepatectomy with lymphadenectomy is safe and feasible in selected patients and by surgeons with expertise in both liver surgery and minimally invasive techniques. The use of hybrid method may be needed for biliary reconstruction, especially in cases where position and size of remnant bile ducts may jeopardize the anastomosis.

Drs. Machado, Makdissi, Surjan, and Mochizuki, have no conflicts of interest or financial ties to disclose.

Runtime of video: 8 mins