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Jacoby et al. Mini-invasive Surg 2022;6:58 https://dx.doi.org/10.20517/2574-1225.2022.58 Page 9 of 11

knowledge, this series of 21 patients who underwent robotic extrahepatic bile duct cancer resection with or
without concomitant hepatectomy is the largest robotic series reported in the Western world so far. Our
results support our hypothesis that robotic resection for hilar cholangiocarcinoma is safe and achieves
excellent postoperative outcomes.

Most of our patients were men in their 70s. All patients presented with obstructive jaundice and underwent
a preoperative drainage procedure, in most cases by ERCP. Preoperative biliary drainage and the best
modality to use (endoscopic via ERCP vs. percutaneous via PTC) are well-known controversial issues in the
management of hilar cholangiocarcinoma; however, preoperative biliary drainage is required prior to most
resections . We have chosen to utilize ERCP for the following reasons. First, our center has a highly skilled
[17]
and experienced advanced endoscopy unit that is capable of successfully performing this procedure with
minimal complications. Second, performing cholangiography is extremely important in clarifying the
anatomy of the biliary tree and it provides better quality information than MRCP. Third, obtaining a
positive biopsy is important, especially before embarking on a complex surgery with the potential for high
morbidity. In recent years, the use of ERCP with cholangioscopy has resulted in significant improvement in
diagnostic accuracy with minimal morbidity. We achieved positive preoperative biopsies in 81% of our
cases, similar to a previous multicenter study . Fourth, preoperative drainage of the future liver remnant is
[18]
necessary for patients who require major hepatectomy because significant cholestasis can impair liver
[19]
function and regeneration following major liver resection . Despite all our drainage efforts, on the day of
surgery, four patients still had bilirubin concentrations of > 3 mg/dL.

The operative time was 458 (433 ± 116.9) minutes and the EBL was 150 (175 ± 123.8) mL. Our results are
superior to other studies on robotic resection of hilar cholangiocarcinoma. A previous series of 10 patients
by Xu et al. reported an operative time of 703 ± 62 minutes with intraoperative blood loss of
1360 ± 809 mL . Another small Western series by Cillio et al. reported a median operative time of 840
[20]
[14]
minutes with an EBL of 700 mL . Poor patient selection and lack of experience in robotic surgery may
have contributed to these results. A meta-analysis by Tang et al. showed a shorter operative time of 207-366
minutes than an open approach; however, the EBL was higher, with reported volumes being
[21]
259-1014 mL . Our low blood loss can be explained by the extensive experience we have gained over some
years: we have used the robotic system to perform more than 400 hepatic resections so far. The robotic
platform provides better visualization with a magnifying 3D camera, tremor filtration, increased dexterity
via a robotic arm with seven degrees of freedom, and a stable platform. This combination of features leads
to the highest possible quality and most precise dissection, resulting in reduced blood loss. Although the
operative time was longer than with open procedures, there were no intraoperative complications or
conversions to an open approach. Moreover, we achieved excellent postoperative outcomes with a short
hospital stay of five days, two (9.5%) major complications (Clavien-Dindo ≥ 3), and one (4.7%)
postoperative mortality at 90 days. Ma et al. compared open vs. laparoscopic surgery for hilar
cholangiocarcinoma and reported a hospital stay of 13.5 vs. 14.7 days, respectively, and a major
complication rate of 14.9% vs. 20%, respectively . A study by Wiggers et al. reported a postoperative 90-day
[22]
mortality rate of 14% .
[23]
As to oncological outcomes, we achieved an R0 resection rate of 90% and a survival rate of 71% over a
follow-up period of almost two years. These results are non-inferior to those of an open series on
cholangiocarcinoma that reported an R0 resection rate of 41%-77% [24,25] . Of interest, a recent study of 708
cases by Mueller et al. defined benchmark values for surgical and oncological outcomes for hilar
cholangiocarcinoma; they cited a benchmark cut-off for R0 resection of ≥ 57% and a benchmark survival
[26]
rate of ≥ 61.5% at two years .