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Page 2 of 11 Jacoby et al. Mini-invasive Surg 2022;6:58 https://dx.doi.org/10.20517/2574-1225.2022.58

Conclusion: Robotic resection of hilar cholangiocarcinoma is safe and feasible and achieves excellent outcomes.
We believe that robotic surgery will soon be an accepted approach for complex hepatobiliary resections, such as
for hilar cholangiocarcinoma.

Keywords: Robotic, hilar cholangiocarcinoma, Klatskin tumor, hepatectomy, bile duct cancer

INTRODUCTION
Hilar cholangiocarcinoma (Klatskin tumor) is a rare and highly aggressive malignancy with a poor
[1,2]
prognosis . Surgical resection is the only potentially curative treatment modality and achieves the best
long-term survival; however, hilar cholangiocarcinoma is one of the most challenging cancers to treat .
[3]
Many factors prejudice the treatment of this complex disease, including its critical location at the confluence
of the bile duct, its aggressive tendency to involve adjacent structures, including major blood vessels, and its
pattern of growth along the biliary tree, which makes it difficult to determine the extent of the disease.
Additionally, resection of hilar cholangiocarcinoma requires systematic portal lymphadenectomy and
[4,5]
complex bilioenteric reconstruction . Given these features, a standard open approach is advocated by
most hepatobiliary surgeons. Some even consider that a minimally invasive approach to hilar
cholangiocarcinoma resection is contraindicated.

The advent of minimally invasive liver surgery (MLS) has marked a new era in hepatobiliary surgery. Over
the past two decades, MLS has been increasingly performed and has achieved better outcomes than an open
approach . A laparoscopic approach to hilar cholangiocarcinoma has been marginally adopted and
[6-8]
reported in small numbers, mostly from China [9,10] . Robotic liver surgery has gone one step further in that
the benefits inherent in using this system have made it possible to perform both the most complex liver
resections and high biliary reconstruction. Previous studies on robotic hepatectomy with biliary
reconstruction for hilar cholangiocarcinoma are limited to small series and case reports; these have shown
that this approach is safe and feasible [11-13] . The largest Western series reported to date included only four
patients . We therefore report here our single institutional experience of 21 patients who underwent
[14]
robotic resection of hilar cholangiocarcinoma. To the best of our knowledge, this is the largest robotic series
ever reported in the Western hemisphere. Our hypothesis was that robotic resection of hilar
cholangiocarcinoma can be performed safely with excellent postoperative outcomes.

METHODS
With institutional review board (IRB) approval, from September 2016 through April 2022, we prospectively
followed 21 consecutive patients who had undergone robotic extrahepatic biliary resection and
reconstruction for hilar cholangiocarcinoma, with or without hepatectomy. Preoperative diagnoses of hilar
cholangiocarcinoma were based on clinical findings, high-quality imaging, advanced endoscopy with
cholangiography, and cholangioscopic biopsy in the majority of cases. Patients with intrahepatic
cholangiocarcinoma, benign or premalignant biliary diseases, and distal cholangiocarcinoma were excluded
from the study.

Patient characteristics and other clinical data collected and analyzed included age, sex, Body Mass Index
(BMI), American Society of Anesthesiology (ASA) score, Childs-Pugh score, Model for End-Stage Liver
Disease (MELD) score, tumor size, jaundice on presentation, preoperative biliary drainage, preoperative
positive biopsy, neoadjuvant treatment, jaundice on day of surgery, operative duration, estimated blood loss
(EBL), Bismuth-Corlette Classification, concomitant hepatectomy, intraoperative complications, lymph
nodes removed, lymph node positivity, margin status, pathological type, postoperative complications