Robotic Right Trisectionectomy, Main Biliary Confluence Resection, Lymphadenectomy, and Hepaticojejunal Reconstruction for Perihilar Cholangiocarcinoma.

Abstract

Surgical resection of perihilar cholangiocarcinoma (PHC) remains the only curative treatment.^{1, 2} Although minimally invasive liver surgery has expanded, major hepatectomies for PHC remain limited because of the technical demands of hilar lymphadenectomy and biliary reconstruction, which are challenging in laparoscopy. Despite the technical advantages of robot-assisted surgery, its role remains debated when it comes to PHC surgery.³ The intent of this video is to present the technique of a robot-assisted extended hepatectomy with biliary reconstruction. A 63-year-old woman with no significant past medical history was diagnosed with PHC following incidental cholestasis discovery. Magnetic resonance imaging and computed tomography revealed a 20-mm Bismuth-Corlette type IIIa PHC, confirmed as well-differentiated on endobiliary biopsy. Preoperative right portal vein embolization enabled future left lobe volume optimization (39% of total liver volume). A robot-assisted right trisectionectomy with main biliary confluence resection (H145678-B), lymphadenectomy (stations 7, 8, 9, 12, 13), and hepaticojejunal reconstruction was performed using the Da Vinci Xi^® system and a standard multiport configuration (four 8 mm robotic trocars and one 12 mm assistant trocar). Operative time was 400 minutes, and blood loss was 150 mL. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 5 after drain removal. Histopathology confirmed a well-differentiated pT1N0(0/13)M0R0 PHC. This case demonstrates the feasibility and safety of robot-assisted extended hepatectomy with biliary reconstruction for PHC in a highly selected patient. Robotic assistance may facilitate precise dissection and reconstruction in the hilum, supporting broader adoption in expert centers pending further comparative data.