Background : Minimally invasive approach is becoming the gold-standard technique in oncological liver resection due to the benefits of this approach when compared to the traditional open operation. The use and adoption of laparoscopic liver resection are hampered by the need for radical portal lymphadenectomy with biliary reconstructions, which is often seen in patients with cholangiocarcinoma. As opposed to the laparoscopic method, the robotic surgical system facilitates precise biliovascular dissections and creation of delicate hepaticojejunostomies. While a single hepaticojejunostomy is considered a technically demanding procedure, dual hepaticojejunostomies are considered contraindication for minimally invasive approach. In this video, we demonstrate the technical feasibility of perihilar cholangiocarcinoma resection with dual hepaticojejunostomies for biliary tract reconstruction.

Methods : A 79-year-old man presented with jaundice, dark urine, weight loss, hyperbilirubinemia, and elevated CA19-9. Preoperative workup revelated severe dilation of the left intrahepatic bile ducts and obstruction at the left hepatic duct. CT scan revealed occluded left portal vein, likely from tumor invasion. ERCP showed malignant appearing biliary structures in the main and left hepatic duct system. The operation began with systematic portal lymphadenectomy, followed by enbloc resection of extrahepatic biliary tree and left hemiliver. The biliary reconstruction was completed with two separate hepaticojejunostomies to right anterior and right posterior sectoral bile duct.

Results : The operative time was 8.5 hours with 75 cc of blood loss. The patient made an uneventful recovery and was discharged home on postoperative day 5. A final pathology showed an 10cm intrahepatic cholangiocarcinoma with negative resection margins. 0/9 lymph nodes were involved by carcinoma.

Conclusions : Robotic Resection of Left Perihilar Intrahepatic Cholangiocarcinoma with Dual Hepaticojejunostomies is safe and feasible. It provides an alternative technique to open and laparoscopic method with increase manual dexterity and precision.