Robotic portal lymphadenectomy with segment 4b and 5 resection for gallbladder cancer

Abstract

Background: Our video describes the use of the da Vinci Surgical System Xi® (Intuitive Surgical, Sunnyvale, CA) to perform a portal lymphadenectomy with resection of segment 4B and 5 of the liver for gallbladder cancer. The patient is a 76 y.o. female who was found to have an incidental pT2pNx gallbladder adenocarcinoma following a laparoscopic cholecystectomy. CT of the chest, abdomen and pelvis were negative for metastasic disease. The procedure was begun with diagnostic laparoscopy which was negative for peritoneal metastasis. Results: The round ligament was taken down using the monopolar scissors and left attached to the under surface of the liver. This was later used as a vascularized pedicle flap to cover the resection bed of the liver at the end of the procedure. Firefly™ fluorescence imaging was used to confirm the junction of the cystic duct stump and the common bile duct. The cystic duct stump was then clipped and divided close to the common bile duct. Intra operative ultrasound was used to identify critical vascular structures and their relationship to the common bile duct and portal lymph nodes. The lymphadenectomy was begun at the lateral aspect of the porta hepatis by incising the peritoneum overlying the porta hepatis and common bile duct. The lateral portal and posterior duodenal lymph nodes were dissected off the common bile duct and portal vein using the mono polar scissors. The lesser omentum was then opened and the hepatic artery lymph nodes were dissected off the hepatic artery. The posterior medial lymph nodes and celiac nodes were also dissected and the specimen was removed en bloc. The EndoWrist® One™ vessel sealer was used to take a wedge of segments 4B and 5 of the liver with a 2 cm margin around the gallbladder fossa. The previously fashioned round ligament flap was then placed into the defect as a vascularized pedicle flap. Final pathology revealed six negative lymph nodes, with a negative cystic duct stump and liver parenchymal margin. The patient’s post-operative course was uneventful and as expected for the procedure.