Laparoscopic Approach for Perihilar Cholangiocarcinoma

Background: Technical advances have allowed to overcome limits which still restricted areas of implementation of laparoscopic liver surgery. The possibility to perform safely major resections, hilar dissection, lymphadenectomy and segment 1 resection has created the scenario for a possible application in the setting of perihilar cholangiocarcinoma (PHC). Technical insights to perform laparoscopic left and right hepatectomy for PHC are provided. Methods: After locoregional lymphadenectomy, dissection of the main bile duct and its distal section is the first step of the hilar dissection. It allows subsequent access to elements of the hepatic hilum. The dissection of the biliary confluence is performed transparenchymally with section of the right/left hepatic duct. Section of hepatic veins is performed by vascular stapler. Segment 1 is resected. Specimen is removed by a short midline incision, used to perform biliary enteric anastomosis. Results: No conversion to open approach was required. Intraoperative frozen sections on distal and proximal margins revealed R0 status in both the procedures. Operation time was 360 and 390 minutes and 10 and 12 nodes were retrieved respectively in left and right hepatectomy. Ascites (Dindo II) was recorded after right hepatectomy. Patients were discharged after 9 and 12 days respectively from surgery. Conclusion: The magnification of images allows a very precise and cautious dissection of the hilum, recognition of structures of the hepatic pedicle and ruling out of vascular infiltration by the disease. PHC still constitutes an indication to laparoscopy only in expert centers, but results seem promising and out the basis for a further widening of indications.