Laparoscopic right extended hepatectomy for perihilar cholangiocarcinoma: surgical technique

Introduction

Hilar cholangiocarcinoma represented approximately 40–60% of all cholangiocarcinomas (1). Surgical resection is the only curative treatment for patients, with a 5-year survival rate ranging from 20% to 40% following radical surgery (2). This tumor is characterized by a low early diagnosis rate and a poor prognosis. Laparoscopic liver surgery (LLS) is gaining wide acceptance over the past decades due to improvements in surgical technology and operative techniques (2). Several studies have already demonstrated the safety of LLS for resection of benign liver disease, colorectal liver metastases and hepatocellular carcinoma (3-5). Although, the minimally invasive approach to treat biliary tract tumors, most often requiring major liver resections and formal hilar lymphadenectomy, represents a technical challenge, several reports in the literature have reported its safety (6-8).

The aim of this study is to provide a step-by-step overview of the technique to perform a minimally invasive right extended hepatectomy associated with hilar lymphadenectomy, resection of the biliary confluence (H15678-B) and Roux-en-Y hepaticojejunal anastomosis for a Bismuth-Corlette type IIIa perihilar cholangiocarcinoma (pCCA), with particular emphasis on technical key points concerning the laparoscopic approach. We present this article in accordance with the SUPER reporting checklist (available at https://ls.amegroups.com/article/view/10.21037/ls-24-32/rc).

Preoperative preparations and requirements

A 59-year-old man with a body mass index of 23 kg/m² with no significant past medical history was referred to our center for a recently diagnosed pCCA discovered upon jaundice and weight loss. On magnetic resonance imaging with magnetic resonance cholangiopancreatography (MRI-MRCP) and computed tomography, a 22 mm × 9 mm tumor was located on the main biliary confluence including both anterior and posterior right biliary ducts (type IIIa Bismuth-Corlette pCCA). No vascular invasion or secondary lesions were observed and there were no signs of chronic liver disease. Blood tests revealed a normal serum carbohydrate antigen 199 (CA199) (24 U/mL) and a serum bilirubin of 53 µmol/L and preoperative biliary drainage was judged unnecessary. A right hepatectomy extended to segment 1, main biliary confluence and extrahepatic bile duct (H15678-B) associated with an extended lymphadenectomy of the hepatoduodenal ligament was decided and validated on a multidisciplinary oncological meeting. The ratio of the future liver remnant volume (FLRV)/total liver volume (TLV) was estimated at 36%, the FLRV/body weight ratio at 0.8% and in the absence of a chronic liver disease, right portal vein embolization was judged unnecessary.

As for all liver surgery in the department, an enhanced recovery after surgery (ERAS) provided a preoperative general evaluation and information of the patient (dedicated consultation for patient/family information and education for the postoperative course of surgery), surgery preparation (assessment of comorbidities, medication, anemia, nutrition and optimization of physical condition with preoperative physiotherapy and rehabilitation), dedicated perioperative anesthesia management (multimodal analgesia with appropriate use of opioids when indicated) and postoperative care (return to normal diet and activities the day of surgery or on after postoperative day (POD) 1, restriction of intravenous fluid administration and early urinary catheter removal) as previously described (9).

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article, accompanying image and video. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

Patient positioning and port placement

Under general anesthesia, the patient was installed in a French position with the first surgeon standing between patient’s legs and having the first and the second assistant respectively on the left and on the right side of the patient. Five ports were placed in a standardized configuration (Figure 1). The abdominal cavity was thoroughly inspected to exclude any tumoral peritoneal seeding. Intraoperative ultrasound was performed to assess liver anatomy and to confirm resectability and relationship between the lesion and main hepatic structures.

Figure 1 Trocars placement. ® indicates the location.

Hilar dissection and lymphadenectomy

The first step consisted in dividing the round and falciform ligament up to the confluence of the hepatic veins. Hepatic pedicle dissection consisted in identification of important vascular landmarks while performing the lymphadenectomy. Lymph node stations removed included stations number 8 and 9 (along the common hepatic artery until up to the coeliac trunk), station number 12 (encompassing regional nodes 12a along the hepatic artery, 12b along the bile duct, and 12p behind the portal vein) and station number 13 (retro-pancreatic nodes in continuity with the 12p group) after performing a Kocher manoeuvre. Dissection of the left hepatic artery confirmed absence of tumoral invasion. Subsequently, the right hepatic artery was dissected, controlled and sectioned. The distal common bile duct (CBD) was sectioned just above the duodenum among locked clips while its distal end was sent for frozen section analysis. Anterior traction of the CBD facilitated portal vein bifurcation dissection. Finally, the right portal branch was dissected free, taped and sectioned between clips.

Liver mobilisation

Once the hepatic pedicle dissection was completed, liver mobilization was performed. The right triangular ligament was sectioned and the right liver lobe was completely mobilized up to the right side of inferior vena cava. Section of the hepatocaval ligament was not performed at that stage since sectioning is usually facilitated at the end of the hepatectomy phase, before sectioning of the right hepatic vein. Left liver mobilization was not necessary, however the Arantius ligament and some short hepatic veins were sectioned, and the Spiegel’s lobe mobilization was initiated in order to facilitate removing the dorsal sector of the liver en-bloc with the right liver.

Parenchymal transection

A Pringle maneuver was placed permitting intermittent vascular hepatic pedicle clamping. The main portal fissure was then progressively opened along the right edge of the middle hepatic vein and in direction to the Arantius groove using a Thunderbeat^® device (Olympus, Japan, Tokyo). Once the parenchymal transection reached the roof of the left hepatic duct, close to the Rex recessus, the latter was sectioned downstream to the junction of segments’ 2–3 and 4 biliary ducts (B2-3-4). A frozen section analysis of the left hepatic duct was performed once the liver specimen was removed. Section of the left hepatic duct enabled access to the Arantius groove and facilitating resection (by pulling aside the left liver) of the dorsal sector en-bloc with the right liver after detaching some remaining short hepatic veins along the inferior vena cava and tracking the Spiegel lobe from left to right behind the hepatic pedicle. Division of the right hepatic vein was finally performed using an endovascular stapler (vascular 35 mm, Ethicon, Cincinnati, OH, USA). The right liver was finally extracted in a plastic bag through a Pfannenstiel incision. Bleeding and bile leak of the cut liver surface were secured. We did not perform bile leak test and we did not prefer the placement of topical hemostatic agents.

Reconstruction

A Roux-en-Y 75 cm jejunal loop was confectioned as we usually performed in pour center. The jejunum was divided with a stapler and a latero-lateral mechanical jejuno-jejunostomy was created at 30 cm from the Treitz ligament. The bile intestinal limp was passed through the transverse mesocolon and behind the gastric antrum up to the left hepatic duct. The technique used for the hepatico-jejunostomy consisted in a single layer interrupted polydioxanone (PDS) 5/0 sutures starting with the posterior layer (Video 1). An abdominal drain was placed near to hepaticojejunostomy anastomosis. Overall blood loss was 250 mL, intermittent hepatic pedicle clamping total time was 45 min and procedure time was 300 minutes.

Postoperative considerations and tasks

The patient received oral feeding on POD 0. The postoperative course was uneventful, other than a spontaneously solved bowel ileus, and the patient was discharged on POD 7. The abdominal drain was removed on POD 5. As we routinely performed, the patient receveid intraoperatively antibiotics prophylaxis. Histopathologic analysis revealed a 20 mm well differentiated pT2aN0R0 cholangiocarcinoma with nine lymph nodes harvested and negative (R0) resection margins according to the tumor-node-metastasis (TNM) classification following the criteria of the 8^th edition of the American Joint Committee on Cancer (AJCC) (10). The patient received 6 months of postoperative capecitabine (11). At 12 months follow up, the patient was doing well, had normal liver function tests and no evidence of local or distant recurrence.

Tips and pearls

• Set up and staging:
  • Use standardized port placement for efficiency and to avoid instrument clash;
  • Intraoperative ultrasound is mandatory for dynamic assessment of anatomy and resectability.
• Hilar dissection:
  • Use the lymphadenectomy (stations 8, 9, 12, 13) as your roadmap to skeletonize the pedicle;
  • Anterior traction on the cut CBD better exposes the portal vein bifurcation.
• Mobilization and transection:
  • Intermittent pringle is key to controlling blood loss;
  • Transect along the right edge of the middle hepatic vein towards the Arantius groove for an anatomically correct plane;
  • Divide the left hepatic duct during transection to access the Arantius groove and facilitate specimen delivery.
• Postoperative:
  • Early feeding & rapid discharge are achievable with a laparoscopic ERAS pathway.

Discussion

In recent years, improvement of surgical skills and growing surgical expertise in minimally invasive surgery have improved the feasibility and safety of laparoscopic extended liver resections as well as patient outcomes (12,13). Despite the broader adoption of major hepatectomies in the last consensus conferences (14,15), laparoscopic liver resections for pCCA remain challenging procedures and restricted to dedicated teams with extensive LLS experience (16,17). Reasons, in the particular setting of pCCA, are hepatic pedicle lymphadenectomy and hepaticojejunal reconstruction that may be challenging to perform in laparoscopy, especially in the case of small ducts or multiple ductal anastomoses. Though introduced more recently, robot-assisted liver surgery (18), has the well-known advantages of a three-dimensional (3D) view and more flexible movements (19) facilitating minimally invasive lymphadenectomy and hepatico-jejunostomies even in the presence of multiple ducts. Although robot-assisted surgery facilitates liver reconstructions compared to laparoscopic procedures, it is associated with longer operative times and higher costs. Additionally, robotic platforms are not widely available (20).

The role of minimally invasive for treating pCCA is steadily increasing in recent years due to its advantages on short postoperative patient outcome (21-23). Ratti et al. compared laparoscopic and open approach for the treatment of pCCA. In their work they showed that intraoperative bleeding (380±250 vs. 470±390 mL, P=0.048) and median hospital stay (10 vs. 14 days, P=0.048) in the LLS group were lower than that in the open surgery group (24). The length of hospital stay and the postoperative complication rate could be evaluated as surrogate markers of time interval from surgery to the beginning of adjuvant chemotherapy. Even if the real benefit of adjuvant chemotherapy in biliary cancers is unclear (25), the possibility to enhance the patient’s access to adjuvant chemotherapy after surgery could theoretically improve surgical outcomes (26). Even if some previous works observed a higher rate of post operative complications and 90-day mortality in the LLS group compared to the open approach, this is probably highly related to the center’s initial experience (5,6), since several studies have underlined the impact of initial patient selection and center expertise on surgical outcomes (27). Our technique describes a pure laparoscopic approach, providing both the first phase of “demolition” which ends with the extraction of the specimen, but also the “reconstruction phase”. The hepaticojejunal anastomosis still represents a technical limitation of the laparoscopic approach, when compared with open and robotic surgery. Some experiences from tertiary hepatobiliary and pancreatic (HPB) centers have already reported different techniques to perform complex surgical procedures in the treatment of pCCA (27,28). Ratti et al. (28) described a hepaticojejunal anastomosis performed by laparotomy using a midline incision serving as the specimen extraction site while Sucher et al. (29) described a ‘parachute technique’ for hepaticojejunostomy in order to perform a laparoscopic running-suture. Nevertheless, performing running suture anastomosis may present limitations, especially when multiple ducts of small size are involved. Our technique involves interrupted suture anastomosis enabling to generalize the technique for all types of anastomoses.

Limitations of our study are its retrospective nature and single center experience which could not be representative concerning intraoperative results and postoperative outcomes. More studies are required to support the indication of minimally invasive for the treatment of pCCA. The diffusion of the robotic platform could represent an alternative to laparoscopy and a more rapid democratization of the minimally invasive approach for liver surgery.

Conclusions

Pure laparoscopic resection for pCCA may be feasible and safe in experienced hands and lead to improved short postoperative outcomes ultimately facilitating patients’ access to adjuvant chemotherapy. In this study we described, step-by-step, a standardized laparoscopic surgical technique for the resection of a type IIIa pCCA.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://ls.amegroups.com/article/view/10.21037/ls-24-32/rc

Peer Review File: Available at https://ls.amegroups.com/article/view/10.21037/ls-24-32/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ls.amegroups.com/article/view/10.21037/ls-24-32/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article, accompanying image and video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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