Background : Gallbladder cancer with extensive bile duct or duodenal involvement often invades the right hepatic artery. Conventionally these patients are managed with open hepatopancreatoduodenectomy that is associated with significant morbidity and mortality. The present video describes the standardized technique of Robotic pancreatoduodenectomy with extended cholecystectomy (segments IVb and V resection) and right hepatic artery ligation without reconstruction for locally advanced gallbladder cancer.

Methods : The procedures are performed with the da Vinci Xi robotic system using four robotic and two assistant trocars. Initially pancreatoduodenectomy is performed to gain access to the hepatoduodenal ligament (HDL) and ensure en-bloc removal of the tumor. After lymphadenectomy and skeletonization of HDL structures, the right hepatic artery is ligated proximal to its involvement by the tumor. Retrograde perfusion of the distal hepatic artery stump through hilar collaterals is confirmed by looking for brisk bleeding. After segment IVb and V resection the bile duct is divided at the level of hilum proximal to the site of biliary infiltration.

Results : Four patients underwent this procedure between October 2022 and September 2023. The median (range) operative time and blood loss were 520 (480-620) minutes and 400 (300-900) mL respectively. Grade B postoperative pancreatic fistula and grade B delayed gastric emptying complicated the postoperative period in one patient. No patient had postoperative liver failure. At a median follow-up of 8 (3-14) months, one patient developed bone metastasis.

Conclusions : Robotic pancreaticoduodenectomy with extended cholecystectomy and right hepatic artery ligation without reconstruction is feasible in selected patients with locally advanced gallbladder cancer.