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Page 8 of 12 Adams et al. Mini-invasive Surg 2023;7:18 https://dx.doi.org/10.20517/2574-1225.2023.12

Figure 2. Complete robotic portal lymphadenectomy for intrahepatic cholangiocarcinoma, with indocyanine green (Firefly) to highlight
biliary anatomy.

demonstrated increased R0 resection rates between RLR and LLR for hepatic malignancies, this difference
has not been borne out in a meta-analysis .
[47]

Studies specific to the robotic approach for ICC are sparse but promising. An NCDB study only identified
72 robotic-assisted cases for stages I-III ICC between 2004 and 2017, compared to 1,804 open cases.
Examining short- and long-term outcomes between RLR and OLR, they found no differences between the
rate of R0 resection, post-operative morbidity, or long-term survival while reducing the length of hospital
stay (6 vs. 9 days, P = 0.019). Notably, there was no difference in LND between groups, which is a striking
[48]
contrast to studies comparing LLR to OLR .

The robotic approach was also demonstrated to improve LND rates and retrieval of at least 6 nodes in
another NCDB analysis by Kim et al., which examined open vs. laparoscopic vs. robotic approaches for both
ICC and gallbladder cancer (GBC). In fact, rates of both R0 resection and retrieval of 6+ nodes were highest
within the RLR group in the combined ICC and GBC group. For ICC only, comparing LLR vs. RLR vs.
OLR, R0 resection was achieved 88.4% vs. 90.1% vs. 85.1%, respectively (P = 0.061), and retrieval of 6+ nodes
in 24.3% vs. 35.3% vs. 26.7% (P = 0.338), respectively. Rates of LND were highest in the OLR group yet low
regardless of approach, 45.9% vs. 43.6% vs. 61.1% (P < 0.001), respectively. Performance of surgery at high
volume and academic centers predicted R0 resection and adequate lymphadenectomy regardless of
approach .
[36]

One of the largest benefits of RLR for biliary tract cancer may be improved lymphadenectomy rates while
also preserving the other benefits of LLR, such as decreased length of stay, decreased morbidity with quicker
recovery, and preserved long-term outcomes [36,43] . Adjuncts, such as indocyanine green (ICG), can also be
easier to utilize on the robotic platform and may help detect tumors and their margins, satellite lesions, or
even metastases [Figure 2] [49-51] .

PATIENT SELECTION
Ultimately, any approach to surgical resection for ICC should include the basic principles of negative
margins and adequate lymph node staging. Surgeons must account for their own technical proficiency and
experience when selecting patients for a minimally invasive approach. Even at expert, high-volume centers,