71: Q&A

Central hepatectomy for liver tumor is a technically challenging hepatobiliary operation which is mainly performed via open method. Technique of minimally invasive laparoscopic liver is emerging however the adoption is slow. In this video, we demonstrated our robotic technique for intrahepatic cholangiocarcinoma located near the hilar plate and right anterior Glisonnean pedicle, previously determined unresectable tumor at an outside hospital.


Methods: A 64-year-old woman presented an abdominal CT scan indicating a 4.1 cm liver lesion in segments 4 and 5. Biopsy was consistent with adenocarcinoma of pancreatobiliary origin (intrahepatic cholangiocarcinoma). Upper endoscopy and colonoscopy did not reveal any malignancy.  The patient had undergone a year of neoadjuvant chemotherapy treatment prior to referral.   


Results: After placement of robotic trocars and pneumoperitoneum, the abdomen was inspected. No carcinomatosis was appreciated. Falciform ligament and perihepatic adhesions secondary to cholecystectomy were divided. Intraoperative ultrasound was utilized to map the intrahepatic anatomy as well as borders of the cholangiocarcinoma margins. The porta hepatis was then dissected. The cystic duct margin was sent for frozen section and confirmed negative for carcinoma.  The right anterior and posterior portal vein and hepatic artery were identified and isolated.  The hilar plate was lowered by taking down Laennec capsule to ensure complete R-0 resections.  The division of the liver parenchyma began along the falciform ligament with a robotic crush-clamp technique and extended vessel sealer. Each individual portal vein and hepatic duct branch were isolated and ligated with clips and/or sutures. The same transfissural approach was employed while transecting along segments 6 and 7. The right anterior Glissonean pedicle was identified. With a meticulous circumferential dissection, the specimen was ultimately removed, enbloc with the gallbladder. Hemostasis was obtained. The patient recovered uneventfully.


Conclusions: This video demonstrates a safe and efficacious application of the robot to a technically difficult extended central hepatectomy with portal lymphadenectomy for intrahepatic cholangiocarcinoma.