Robot-Assisted Laparoscopic Trisegmentectomy 2.3.4 with Lymph Node Resection for Intrahepatic Cholangiocarcinoma

Radical resection remains the only potentially curative treatment for intrahepatic cholangiocarcinoma. Despite the increasing adoption of minimally invasive liver surgery, reports on laparoscopic or robotic approaches for intrahepatic cholangiocarcinoma remain limited, especially when oncologic principles such as lymphadenectomy must be respected. This video presents a robot-assisted left hepatectomy extended to the middle hepatic vein, combined with systematic lymphadenectomy, for a left-sided intrahepatic cholangiocarcinoma involving the middle hepatic vein.

A 79 year-old female patient presented with abdominal pain. Computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed an intrahepatic cholangiocarcinoma in contact with the middle hepatic vein, without evidence of extrahepatic metastasis. Resection was indicated following multidisciplinary tumor board discussion. Left hepatectomy (H234-MHV) was performed using the Da Vinci Xi® robotic system. Four robotic trocars (three 8 mm and one 12 mm) and two assistant trocars were placed. Intraoperative ultrasound confirmed involvement of the middle hepatic vein. Systematic hilar lymphadenectomy (stations 12, 8, 9, and 7) was performed. Parenchymal transection was achieved using the clamp-crush technique. The bile duct was divided upstream of the confluence.

Operative time was 245 min, with a cumulative Pringle time of 51 min. R0 resection was achieved, and nine lymph nodes were retrieved, two of which were metastatic. There were no postoperative complications, and the patient was discharged on postoperative day 3.

This video highlights that the Da Vinci Xi® platform enables safe execution of complex liver resections with lymphadenectomy. While laparoscopic techniques have been increasingly standardized, significant intercenter variability persists in robotic liver surgery, warranting detailed procedural reporting.