Robotic left hemihepatectomy with lymph node dissection for a large intrahepatic cholangiocarcinoma

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Purpose: Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver tumor following HCC. The incidence of ICC is low in most parts of the world. However, incidence has been rising. The only curative treatment option involves surgical resection as part of a multidisciplinary treatment. The goal of surgery is to obtain negative section margins while leaving an adequate future liver remnant. The role of regional lymphadenectomy is still debated, as it might add to a higher postoperative morbidity. An expert consensus statement states that regional lymphadenectomy should be considered a standard part of surgical therapy for patients undergoing resection of ICC. Another question remains about the role of minimal invasive surgery for ICC. A laparoscopic approach may lead to lower morbidity without compromising oncological adequacy. However, some doubts remain about the extent of lymph node dissection in laparoscopic approach. This video aims to demonstrate the advantages of a robotic approach using the Da Vinci© XI for left hemihepatectomy with lymph node dissection for a large intrahepatic cholangiocarcinoma. Methods: After screening for hepatic of peritoneal metastases, an extensive lymph node dissection of lymph node groups one and two is performed. Hilar structures are divided selectively. Next, a left hemihepatectomy is performed using the robotic vessel sealer. Finally, the left hepatic vein is divided using a vascular stapler and resection is finished. Results: Operative time was 270 min and blood loss was 20ml. The postoperative course was uneventful and the patient was discharged on postoperative day 3. Pathologic investigation showed an intrahepatic cholangiocarcinoma of 5cm, with tumorfree margins of 17mm. 0/10 lymph nodes were positive. Conclusions: The robotic approach to major hepatectomy with lymph node dissection for intrahepatic cholangiocarcinoma is safe and feasible with an acceptable number of lymph nodes prelevated.