ROBOTIC TYPE 3B KLATSKIN TUMOR RESECTION. TECHNIQUE OF UNIFICATION DUCTOPLASTY FOR RY BILIARY RECONSTRUCTION.

Minimally invasive resection for perihilar cholangiocarcinoma is an emerging technique in HPB surgery which requires both liver resection and biliary reconstruction. Description of this method is very limited. In this video, we described a Bismuth 3A perihilar cholangiocarcinoma resection in a 77-year-old man, who presented with intrahepatic ductal dilation (Right >Left) and jaundice. ERCP/cholangioscopy shows a high-grade bismuth 3A with malignant stricture. An endoscopic preoperative drainage was achieved with a 7 French 15cm plastic stent. The robotic resection of Klatskin type 3A was completed uneventfully with adequate lymphadenectomy and unremarkable postoperative course.

A 67-year-old male patient with upper abdominal discomfort for 2 months and jaundice for 1 month. CT scan demonstrated hilar mass with portal vein invasion. PTCD was performed 10 days ago. This patient was successfully treated with right hepatectomy and caudate lobectomy together with portal vein reconstruction. The portal vein invaded by the tumor was removed and end-to-end anastomosis was performed. Then, the biliary-enteric anastomosis was completed between the left hepatic duct and the jejunum in an end-to-side way. The hospital stayed is 18 days. This patient obtained rapid recovery without severe postoperative complications. Postoperative CT and laboratory examination were normal.

A middle-aged male was admitted to the hospital with pruritus and jaundice. Enhanced computed tomography demonstrated the wide extension which involved the portal vein, and the right posterior hepatic artery originates from the mesenteric artery. According to these, I/V/VIII segment resection was scheduled. The portal vein involved was removed. Then end-to-end anastomosis was performed. Finally, biliary enteric anastomosis was completed in an end-to-side way. The scheduled R0 resection had been achieved. Surgical procedures cost 10 hours with 200ml bleeding. The postoperative course was uneventful. Pathological examination revealed that R0 resection was performed.

For gallbaldder cancer patients with T1b or higher disease, radical cholecystectomy including partial hepatectomy and porat hepatic lymph node dissection (PHLND) is recommended. PHLND is a technical demanding procedure regardless in open or minimally invasive surgery.

Author presented a novel and standardized method to demonstrate the key techniques for PHLND with robotic platform with the following goals:
1. To help fellows and junior attendings to understand and to mast the skills for porta hepatis lymph node dissection in the open approach by demonstrating the key steps and anatomy.
2. It provided a road map for those surgeons who are interested in robotic radical cholecystectomy.

Minimally invasive approach for perihilar cholangiocarcinoma is an emerging technique. The difficulty with laparoscopic bilioenteric anastomosis at or above the level of hilar plate is a limiting factor in laparoscopic technique. We describe our robotic technique in unifying right posterior and anterior sectoral duct to create a single hepaticojejunostomy anastomosis after a type 3B Klatskin tumor resection. The operative time was 8 hours with an uneventful postoperative recovery. Pathology report showed cholangiocarcinoma involving the left hepatic duct and, and proximal common hepatic duct, with microscopic invasion into the left lobe (2.1 cm). The JP drain was removed prior to discharge.