Background : Only 20% of patients with hilar cholangiocarcinoma can undergo a formal hepatectomy owing to poor liver function and performance status. Patients with bismuth type II tumors with inadequate future liver remnant may be candidates for hilar bile duct resection. Due to complex dissection and reconstruction minimally invasive approach is not commonly used. The technique of robotic hilar bile duct resection for hilar cholangiocarcinoma is described in this video.

Methods : The procedures are performed with the da Vinci Xi robotic system using four robotic and two assistant trocars. After hepatoduodenal ligament (HDL) lymphadenectomy the lower end of the bile duct is divided and the bile duct margin is sent for frozen section examination. Partial resection of segment IV is performed to have wide exposure to the hilum. The Left and right hepatic ducts were transected beyond the secondary confluence, and the ductal margins were sent for frozen section examination. After ensuring negative margins hepaticojejunostomy. Despite multiple duct openings all are present at the level of the hilar plate. Hence, a single anastomosis to the hilar plate incorporates all the ductal openings.

Results : Four patients underwent this procedure between August 2022 and October 2023. The median (range) operative time and blood loss were 480 (400-610) minutes and 350 (200-650) mL respectively. One patient had a bile leak in the postoperative period . At a median follow-up of 8 (2-14) months, all patients are free of recurrence.

Conclusions : Robotic hilar bile duct resection is feasible and safe in selected patients with hilar cholangiocarcinoma.