Complete Laparoscopic Radical Resection of Perihilar Cholangiocarcinoma Type IIIb

Podsumowanie

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With continuous advancements in laparoscopic techniques and instruments, laparoscopic radical surgery for pCCA is now considered technically safe and feasible. However, due to the high complexity of the surgery and the lack of evidence-based clinical support, laparoscopic radical surgery for type IIIb pCCA is performed only in a few large hepatobiliary centers. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA. Therefore, in this article, we provide a detailed description of the surgical steps and technical points of complete laparoscopic left hemihepatectomy combined with total caudate lobectomy, regional lymphadenectomy, and right hepatic duct-jejunal Roux-en-Y anastomosis in patients with type IIIb pCCA, using fluorescence navigation technology to enhance surgical precision and safety. By adhering to standardized surgical procedures and precise intraoperative techniques, we offer an effective means to improve patient outcomes.

Streszczenie

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With continuous advancements in laparoscopic techniques and instruments, laparoscopic radical surgery for pCCA is now considered technically safe and feasible. However, due to the high complexity of the surgery and the lack of evidence-based clinical support, laparoscopic radical surgery for type IIIb pCCA is performed only in a few large hepatobiliary centers. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA. Therefore, in this article, we provide a detailed description of the surgical steps and technical points of complete laparoscopic left hemihepatectomy combined with total caudate lobectomy, regional lymphadenectomy, and right hepatic duct-jejunal Roux-en-Y anastomosis in patients with type IIIb pCCA, using fluorescence navigation technology to enhance surgical precision and safety. By adhering to standardized surgical procedures and precise intraoperative techniques, we offer an effective means to improve patient outcomes.

Wprowadzenie

Perihilar cholangiocarcinoma (pCCA), also known as Klatskin tumor, was first described by Gerald Klatskin and is a malignant tumor that occurs in the bile duct epithelium at the confluence of the right and left hepatic ducts¹. This disease is highly malignant and aggressive, often presenting with jaundice and cholangitis in advanced stages. Despite advancements in diagnosis and treatment, the prognosis for pCCA remains poor, with radical surgical resection still being the only potentially curative approach. Such surgeries typically involve extensive hepatectomy, bile duct resection, and regional lymphadenectomy². The goal of surgery is to achieve an R0 resection, which significantly improves patient survival rates^3,4. However, the complex anatomy of the hilar region and the tumor's proximity to vital vascular structures make these surgeries highly challenging.

In recent years, the advent of laparoscopic technology has revolutionized surgical oncology, offering potential advantages such as reduced perioperative complications, shorter hospital stays, and faster recovery^5,6,7. Nevertheless, the application of laparoscopic surgery in pCCA, particularly for type IIIb cases, remains limited, with only a few reports available^3,8. This is primarily due to the technical difficulty in achieving adequate margins and performing complex biliary and vascular reconstructions laparoscopically⁹. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA^4,10,11,12. However, evidence supporting the use of laparoscopic methods for this extensive surgery is still accumulating.

This study presents the complete laparoscopic radical resection of type IIIb pCCA. We aim to detail this surgery's techniques and key steps, including left hemihepatectomy, total caudate lobectomy, regional lymphadenectomy, and Roux-en-Y hepaticojejunostomy. By sharing this protocol, we hope to contribute to the evidence supporting the feasibility and safety of laparoscopic methods in the treatment of type IIIb pCCA, ultimately improving patient outcomes.

Protokół

The study follows the human research ethics committee of the Second Affiliated Hospital of Nanchang University. Written informed consent was obtained from the patient prior to surgery.

NOTE: The patient was a 65-year-old male presenting with a chief complaint of "generalized jaundice and pruritus for 2 weeks". A computed tomography (CT) scan at an outside hospital revealed a perihilar bile duct mass with intrahepatic bile duct dilation. The surgical instruments and equipment used are listed in the Table of Materials.

1. Preoperative preparation

1. Perform routine blood tests preoperatively, including complete blood count, liver and kidney function tests, coagulation profile, and serum tumor markers.
   1. Draw blood samples, send them to the laboratory for various blood tests, and report the results.
      NOTE: Liver function tests showed elevated total bilirubin (230.8 μmol/L) and decreased albumin (35.7 g/L). Serum tumor marker tests revealed elevated carbohydrate antigen carbohydrate antigen 199 (184.46 U/mL)^4,12.
2. Perform preoperative electrocardiogram (ECG), abdominal CT, magnetic resonance imaging (MRI) of the abdomen, chest CT, and other relevant examinations^4,12.
   NOTE: In this study, the patient underwent an abdominal CT scan with and without contrast in the radiology department. The scan showed a mass in the perihilar region without involvement of surrounding vessels, suggesting cholangiocarcinoma with obstruction (Figure 1). MRI with and without contrast and magnetic resonance cholangiopancreatography demonstrated a mass in the perihilar bile duct and adjacent liver parenchyma with intrahepatic bile duct dilatation and enlarged perihilar lymph nodes, indicating a neoplastic lesion (Figure 1).

2. Surgical procedure

1. Administer general anesthesia with tracheal intubation, intravenous and inhalational agents. Position the patient supine with the head elevated and legs apart. Perform routine disinfection using povidone-iodine solution.
   NOTE: The primary surgeon stands on the patient's right side, the assistant on the left side, and the camera holder between the patient's legs (Figure 2).
2. Make a longitudinal incision of approximately 1 cm at the umbilicus, insert a Veress needle, and insufflate CO₂ to maintain an intra-abdominal pressure of 12 mmHg. Insert a 10 mm trocar and a 30° laparoscope. After confirming no distant metastasis via laparoscopy, place the surgical trocars as shown in Figure 2.
3. Dissect the cystic artery and cystic duct, then proceed with the retrograde removal of the gallbladder. Use an ultrasonic scalpel to dissect, mobilize, and suspend the common hepatic artery (CHA), gastroduodenal artery (GDA), proper hepatic artery (PHA), and the left hepatic arteries (LHA) (giving off the middle hepatic artery (MHA)) and right hepatic arteries (RHA). Ligate and divide the right gastric arteries (RGA) and LHA (Figure 3).
4. Transect the common bile duct (CBD) at the superior border of the pancreas and send the distal margin for frozen section pathology to confirm negative margins.
5. Use an ultrasonic scalpel to dissect, mobilize, and suspend the portal vein (PV). Remove the extrahepatic bile duct and lymph node groups 8, 12, and 13 en bloc along the PV towards the hepatic hilum, achieving skeletonization of the hepatoduodenal ligament.
6. Ligate and divide the left branch of portal vein (LPV) and caudate lobe portal vein branches.
   1. Dissect the left hepatic ligaments and divide the short hepatic veins of the caudate lobe, clearly delineating the demarcation line (ischemic line) between the right and left liver lobes.
   2. After marking the demarcation line, confirm that the fluorescence boundary matched the ischemic line using fluorescence imaging (Figure 4, and Figure 5).
      NOTE: A negative staining method is used here, with indocyanine green administered via peripheral intravenous injection at a dose of 0.25 mg^13,14.
7. Intermittently occlude the main PV using the Pringle maneuver¹⁵. Use an ultrasonic scalpel to transect the liver parenchyma along the demarcation line, then along the plane of the middle hepatic vein (MHV), ensuring to divide its V4b and V4a branches.
   NOTE: Patients with a positive liver margin may consider undergoing expanded left hepatectomy (LH), which involves the complete resection of the main trunk of the MHV and the left portions of segments 5 and 8. This approach may improve survival rates¹⁶.                
8. Transect the right hepatic duct approximately 1 cm from the tumor and send the proximal margin for frozen section pathology to confirm negative margins.
   1. Perform intraoperative frozen section analysis of the proximal hepatic duct margin multiple times as needed to ensure an R0 resection. If the right hepatic duct is extensively divided, consider bile duct reconstruction or double hepaticojejunostomy of the right anterior and right posterior bile ducts.
9. Transect the left hepatic vein (LHV) using an endoscopic linear cutter stapler (ENDO-GIA). Completely resect the left hemiliver and the entire caudate lobe, and place the specimen in a retrieval bag (Figure 6).
10. Transect the jejunum approximately 20 cm distal to the ligament of Treitz. Elevate the distal loop posterior to the colon for an end-to-side anastomosis with the right hepatic duct, using continuous sutures for the anterior and posterior walls (Figure 7). Perform a side-to-side jejunojejunostomy approximately 45 cm distal to the right hepatic duct-jejunal anastomosis.
11. Irrigate the abdominal cavity with sterile distilled water. Carefully inspect the surgical field for active bleeding, bile leaks, and gastrointestinal side branch injuries. Place drainage tubes in the left liver section and Winslow's foramen.
12. Extend the umbilical incision by approximately 5 cm and dissect the abdominal wall layer by layer to retrieve the specimen. Verify the count of surgical instruments and gauze. Remove the trocars under direct vision. Close the abdominal wall incision with interrupted 2-0 absorbable sutures to complete the surgery.

3. Postoperative care

1. Transport the patient safely back to the ward after the patient regains consciousness.
2. Administer intravenous antibiotics, omeprazole, and nutritional support postoperatively.
3. Start a liquid diet on the third postoperative day after the patient passes gas.
4. Remove the abdominal drainage tubes on the 4^th and 13^th postoperative days.

Wyniki

The surgery progressed smoothly, and intraoperative frozen section pathology showed negative margins at both the distal and proximal bile ducts. Throughout the procedure, the patient's vital signs remained stable, and anesthesia was effective. The operation lasted 360 min, with PV occlusion time totaling 60 min (15 min + 5 min × 4 times). Intraoperative blood loss was 400 mL, and the patient received 2 units of leukocyte privative red blood cells and 600 mL of fresh frozen plasma. Postoperative flatus was observ...

Dyskusje

pCCA is a common malignant tumor of the bile ducts, with radical surgical resection being the only potential curative treatment². Traditional radical surgery for pCCA typically requires an abdominal incision of 20–30 cm, resulting in significant surgical trauma. Large incisions often cause considerable postoperative pain, affecting patient comfort and recovery, thereby prolonging hospital stays^5,6,7...

Materiały

Name	Company	Catalog Number	Comments
5-mm trocar	CANWELL MEDICAL Co., LTD	179094F	Sterile, ethylene oxide sterilized, disposable
12-mm trocar	CANWELL MEDICAL Co., LTD	NB12STF	Sterile, ethylene oxide sterilized, disposable
Absorbable Sutures	America Ethicon Medical Technology Co., LTD	W8557/W9109H/VCPB839D	Sterile, ethylene oxide sterilized, disposable
Alligaclip Absorbable Ligating Clip	Hangzhou Sunstone Technology Co., Ltd.	K12	Sterile, ethylene oxide sterilized, disposable
Endoscopic linear cutting stapler	America Ethicon Medical Technology Co., LTD	ECR60W/PSEE60A	Sterile, ethylene oxide sterilized, disposable
Non-absorbable polymer ligature clip	Greiner Bio-One Shanghai Co., Ltd.	0301-03M04/0301-03L04/0301-03ML02	Sterile, ethylene oxide sterilized, disposable
NonAbsorbable Sutures	America Ethicon Medical Technology Co., LTD	EH7241H/EH7242H	Sterile, ethylene oxide sterilized, disposable
Ultrasonic scalpel	America Ethicon Medical Technology Co., LTD	HARH36	Sterile, ethylene oxide sterilized, disposable