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Page 2 of 12 Adams et al. Mini-invasive Surg 2023;7:18 https://dx.doi.org/10.20517/2574-1225.2023.12

[7]
ICC, including those with resectable disease . Therefore, a surgical approach that supports rapid recovery
and return to function with minimal disruption to quality of life is especially appealing.

Minimally invasive surgical (MIS) approaches, particularly laparoscopic liver resection (LLR), are well
described in the treatment of HCC and colorectal liver metastasis and are associated with improved short-
term outcomes [8-11] . However, MIS treatment of ICC, whether via LLR or robotic liver resection (RLR), has
not been well-studied, and its description is mostly limited to retrospective single-center studies from high-
volume, expert centers. For instance, in a large systematic review including 2,804 patients comparing open
liver resection (OLR) to LLR for malignant liver tumors, ICC was lumped with other metastatic liver tumors
and altogether only accounted for 7% of included patients . With acknowledgment of the limited data, this
[12]
review examines the state of the current literature comparing open, laparoscopic, and robotic approaches
specific to ICC.

METHODS
This review aims to summarize the existing data on short-term and long-term outcomes of open,
laparoscopic, and robotic approaches to surgical resection of ICC. PubMed was searched for terms
including “intrahepatic cholangiocarcinoma,” “minimally invasive,” “laparoscopic”, and “robotic”, with a
search end date of January 31, 2023. Short-term outcomes included operative time, percent conversion,
intraoperative blood loss, major complications (Clavien Dindo grade 3a unless otherwise noted), length of
stay, and 30-day mortality. Oncologic outcomes include percent of patients receiving R0 resection, lymph
node dissection (LND), and ≥ 6 lymph nodes harvested. The long-term oncologic outcomes, including
total percent recurrence, 1-year and 3-year overall survival (OS), and 1-year and 3-year disease-free
survival (DFS), were also reported.

PRINCIPLES OF TREATMENT
Most patients are considered unresectable at presentation, as the tumor is often locally advanced or
metastatic prior to causing symptoms . Contraindications to resection include metastatic disease, nodal
[4]
disease beyond the regional basin (N2 disease), and invasion of the common hepatic artery or both the right
and left hepatic arteries [13-15] . Relative contraindications include multifocal tumors and portal vein
involvement, although, in experienced centers, portal vein resections and reconstructions may be performed
in selected patients [16,17] . In addition, due to the tendency of ICC for intraductal and periductal spread, major
hepatectomies are often required, necessitating a sufficient future liver remnant (FLR) or sufficient
hypertrophy of the FLR following augmentation strategies such as portal vein embolization (PVE) [18,19] .

Few patients present with resectable disease, and surgery remains the only potentially curative treatment for
ICC [5,13,20] . Principles of surgical resection include total excision of the tumor with negative margins and
removal of locoregional nodes, particularly stations 8 and 12 [6,15,21-23] . There is no evidence to support the
need for an anatomic resection as long as negative margins can be obtained. Even at the time of surgery,
resectable ICC is associated with lymph node metastases in 40% of patients, and LND should be performed
routinely . The 8th edition of the AJCC classification system recommends harvest of at least 6 nodes for
[24]
[25]
adequate staging .
While minimally invasive approaches are often associated with less morbidity, improved quality of life, and
shorter length of stay, this approach cannot compromise the basic oncologic tenets of negative surgical
margins and adequate LND. High-quality data are lacking regarding these critical aspects of MIS
management of ICC, but many retrospective cohort studies have evaluated its feasibility, short-term
outcomes, and oncologic outcomes. It is important to interpret these studies in the context of inherent