Laparoscopic Surgery for Extrahepatic Cholangiocarcinoma: Focus on Biliary Reconstruction

Abstract

Background: Laparoscopic surgery of perilar cholangiocarcinoma, despite technical difficulties, constitutes a milestone in the implementation of a minimally invasive program: indeed it confers significant perioperative advantages compared to the open approach. The main limitation to its large-scale diffusion is represented by the need to perform biliary reconstruction. The purpose of this video is to provide details for a reproducible, safe and effective technique focusing on this step. Methods: After locoregional lymphadenectomy, the main biliary tract is isolated and dissected in its suprapancreatic portion(distally) and at the biliary confluence(proximally). Biliary anastomosis is performed on a defunctionalized Y- loop anchored to the round ligament. The reconstruction technique reproduces the open one: in particular, the posterior wall - performed by interrupted suture - involves the use of the parachute technique. For the anterior wall, interrupted sutures are instead affixed directly. The retrieval of the specimen is done through a small enlargement of the supraumbilical incision. Results: Preoperative staging revealed a Bismuth type I cholangiocarcinoma. The overall length of the procedure was 350 minutes. Blood losses were 100 mL. The specimen was sent for intraoperative frozen section on both the proximal and distal margin which were negative for neoplastic infiltration. Ten nodes were removed by dissection of stations 8 and 12. The postoperative hospital stay (8 days) was uneventful. Final staging at pathology was pT1, pN0, G2. Conclusion: Biliary reconstruction performed laparoscopically is technically feasible, but requires careful planning of surgical steps and great attention to teamwork. The creation of the ideal conditions, i.e. a good exposure of the surgical field and the magnification provided for intraoperative images, is an essential prerequisite for the implementation of this technique.