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Adams et al. Mini-invasive Surg 2023;7:18 https://dx.doi.org/10.20517/2574-1225.2023.12 Page 9 of 12

specific tumor characteristics disqualified patients from a laparoscopic approach. These characteristics
include lesions that require biliary or vascular resections, lesions infiltrating the inferior vena cava, and
[42]
lesions in contact with the hepatic vein of the FLR . However, the robotic platform may expand the patient
selection criteria due to more dexterity and technical capabilities, with increased ability to suture, dissect
larger tumors, and access the posterosuperior segments .
[45]
At our institution, we routinely offer MIS hepatectomy for ICC, and our preferred approach for this is the
robotic platform, which, in our experience, has allowed for expanding criteria for MIS, reduced the learning
curve, and facilitated the performance of LND, which should be standard practice for this disease. Of
course, the experience and technical ability of the surgeon should also be taken into account, as individual
surgeons should recognize the limit of their abilities on the MIS platform - as they should with open surgery
- in deciding which patients should be offered this option. Guiding principles of R0 resection and adequate
lymphadenectomy are crucial and cannot be discarded for the sake of a MIS approach. Academic centers
and high-volume minimally invasive centers demonstrate the highest rate of achieving these oncologic
principles and are associated with the best long-term outcomes for this highly select group of patients .
[36]
CONCLUSION
Although high-quality, randomized data do not yet exist comparing open, laparoscopic, and robotic
approaches to resection of ICC, multiple cohorts and meta-analyses demonstrate comparable short- and
long-term outcomes between OLR and LLR. It should be noted that while we attempted to comprehensively
include all studies specifically comparing surgical approaches for ICC, this is not a true systematic review
nor meta-analysis, and conclusions must be drawn with caution, especially as it does not include any
randomized data. Rather, we submit this review in the context of the approach of our group to the surgical
treatment of ICC. Acknowledging the limitations of the data, benefits of LLR may include decreased length
of stay and decreased morbidity while preserving survival outcomes. However, a major shortcoming in LLR
is the decreased rate of LND, likely secondary to technical difficulty. The robotic platform may facilitate
adequate lymph node harvest and expand minimally invasive options for more complex tumor locations
and major hepatectomies.

DECLARATIONS
Authors’ contributions
Made substantial contributions to the conception, outline, drafting, and editing of the manuscript: Adams
AM, Tran Cao HS

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.