Challenges and Technical Innovations for an Effective Laparoscopic Lymphadenectomy in Liver Malignancies

Intrahepatic cholangiocarcinoma (ICC) and gallbladder cancer (GC) are relatively uncommon indications for minimal invasiveness, mainly due to the technical complexity required for a laparoscopic loco-regional lymphadenectomy. The aim of this presentation is to provide a step-by-step overview for the technical approach to laparoscopic lymphadenectomy of the hepatic pedicle and parenchymal transection.

Two cases of an ICC and a GC are shown. Patients were placed supine in the modified French position. One optic port was inserted through open access and four more operative trocars were placed under direct vision in a standardized fashion. Lymphadenectomy of the common hepatic artery (station 8) and of the hepato-duodenal ligament for proper hepatic artery, common bile duct, and portal vein (stations 12A, 12B, and 12P, respectively) is shown. Parenchymal transection is depicted using alternation of an energy device with an ultrasonic aspirator, while intrahepatic vascular structures are sealed with bypolar forceps, clips, or stapled according to dimension.

In the first case operative time was 210 minutes, lymphadenectomy time (LT) 40 minutes, and estimated blood loss (EBL) 200 mL. Final pathology was consistent with ICC pT2N1(1/7)M0. In the second case, operative time was 180 minutes, LT 35 minutes, and EBL 150 mL. Final pathology reported gallbladder adenocarcinoma pT2N0(0/7)M0. Postoperative courses were uneventful; drains were removed on postoperative day (POD) 2. Patients were discharged on POD 3.

Overcoming the technical limitation embodied by the need of performing an appropriate lymphadenectomy represents the milestone for having patients affected by primary biliary tumors of the liver enrolled to laparoscopy; therefore, this subgroup of patients can benefit from the advantages offered by minimal invasiveness. The leading assumption, however, remains the requirement of performing an oncologically adequate lymph nodal dissection.