Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

This is the first clinical application study for robotic Taj Mahal hepatectomy for hilar cholangiocarcinoma. It follows the principle of radical tumor section and can obtain a higher resection margin within P or U point, ensuring the negative rate of longitudinal and transverse resection margin. The robotic approach for the treatment of hilar cholangiocarcinoma is well applied currently.

This video would be helpful for the surgeon who begins to perform robotic resections of hilar cholangiocarcinoma. To begin, perform a full abdominal inspection using robotic endoscopy to observe the shape and size of the liver, gallbladder, and hepatoduodenal ligament, assessing for tumor resectability. Dissect the lesser omentum from right to left with an electrocoagulation hook to descend the pylorus and duodenum.

Then, create a Kocher's incision about five centimeters at the lateral side of the second part of the duodenum using an electrocoagulation hook to expose the retroduodenal portion of the common bile duct. Clip the distal and proximal stump of the common bile duct with an absorbable ligating clip. Then, transect the common bile duct in the superior edge of the pancreas using curved shears.

Dissect the common bile and hepatic duct from caudal to cephalad toward the cystic triangle. Then, dissect the cystic triangle using an electrocoagulation hook and determine the relationship between the tumor, hepatic artery, and portal vein. After ligation, with an absorbable ligating clip, transect the cystic duct and artery using curved shears.

Then, remove them and the gallbladder from the gallbladder bed. Dissect the hepatic artery and portal vein using the intra-Glissonean approach with an electrocoagulation hook and bipolar forceps. Identify the position of the gastroduodenal artery, common hepatic artery, and portal vein and fasten them with a rubber band.

Skeletonize arteries and veins in the hilar region using an electrocoagulation hook and bipolar forceps. Dissect the hepatoduodenal ligament and transect the common bile duct from bottom to top. Continue dissecting the bile duct, proper hepatic artery, and portal vein completely with an electrocoagulation hook and bipolar forceps.

Then, transect their branches with an ultrasonic scalpel to expose arteries and veins one by one. Resect the 8A, 8P, and 12 lymph nodes, peripheral nerve connective tissue, and hepatic portal plate with the electrocoagulation hook. Mobilize the left and right portal veins and the left portal vein.

Then, transect the branches of the portal vein from the right caudate lobe using an ultrasonic scalpel. Label the resection line of S4b, S5, and the caudate lobe on the liver's surface using an electrocoagulation hook. Then, transect the perihepatic ligaments and dissociate the bilateral halves of the liver using an electrocoagulation hook and bipolar forceps.

Expand the Kocher's incision using an ultrasonic scalpel and an electrocoagulation hook. Resect lymph nodes 13a, 16a2, and part of the 7 and 9 groups using an ultrasonic scalpel and bipolar forceps. Remove these lymph nodes together with the previously dissected lymph nodes to achieve and block regional lymphadenectomy, which could also improve the exposure of the left caudate lobe.

Transect the hepatic round ligament and its falciform ligaments using an electrocoagulation hook and bipolar forceps. Correct the resection line to expose intrahepatic bile ducts sufficiently, according to the actual situation during surgery. Occlude the left Glissonean pedicle with bulldog clamps and transect the left liver parenchyma along the resection line with an ultrasonic scalpel.

Similarly, occlude the right Glissonean pedicle and transect the right liver parenchyma. Ligate the branches of the intrahepatic Glissonean system and hepatic veins using surgical clips, and use an ultrasonic scalpel for parenchymal transection. Completely resect S4b and S5.Transect the liver parenchyma of the caudate lobe and the Spiegel lobe.

Finally, transect the ventral-caudal portion of S1.Examine the cut surface of the liver and close the bile duct orifice of the caudate lobe with 4-0 sutures. Use an electrocoagulation hook to stop small bleeds and bile leakage, while a 4-0 suture stops larger bleeds and bile leakage. Next, insert silicon stents into the branches of the left and right hepatic ducts to confirm the location of the ducts.

Remove the stents and suture the adjacent walls of the right and left hepatic duct branches with 4-0 sutures. When the adjacent branches are sufficiently close, reconstruct the adjacent hepatic duct branches into an arch with a septum using a C4 suture. Close the remaining small bile duct orifice with 4-0 sutures.

Then, cover the cut surface of the liver with a hemostatic sponge. Open the gastrocolic ligament with an electrocoagulation hook and ultrasonic scalpel. Then, open the avascular area on the left of the vessels of the middle colic artery to expose the jejunum.

Retract the proximal jejunum through the transverse mesocolon. Perform the retrocolic hepaticojejunostomy about 20 centimeters away from the ligament of Treitz for the left hepatic duct using a CV4 suture in the hypotonic position of the jejunum. Using the same method, perform the hepaticojejunostomy for the right hepatic duct and jejunum and finish the bilateral hepaticojejunostomy.

Transect the jejunum and jejunal mesentery using a cutting stapler away from the proximal stump of the biliary enteric anastomosis. Perform a side-to-side jejunum jejunostomy with the cutting stapler about 45 centimeters away from the distal stump of the biliary enteric anastomosis. Examine the cut surface of the liver and anastomosis sites and eliminate bleeding and bile leakage, as described earlier.

Place two drainage tubes at the anterior and posterior areas of the biliary enteric anastomosis, respectively. In this surgery, the Taj Mahal hepatectomy was successfully completed with trimming of the hepatic ducts and the anastomosis of the bilateral hepaticojejunostomy. The total operative time was 340 minutes, with an estimated blood loss of 100 milliliters.

After surgery, the drain was removed and the patient was discharged on day 17. The patient had no laboratory and radiological evidence of recurrence or metastasis, three months postoperatively. Compared to the conventional operation, the robotic Taj Mahal procedure significantly reduces the damage to normal liver tissue, preserves more normal liver T-cells, and reduces the occurrence of serious postoperative complications, such as acute liver failure.