Robotic Hepatoduodenal and Cardinal Lymphadenectomy during Hepatectomy for Left-Sided Intrahepatic Cholangiocarcinoma

Surgery is currently the only curative treatment for resectable intrahepatic cholangiocarcinoma. Guidelines recommend lymphadenectomy for all resections with curative intent, but the extent of lymphadenectomy remains controversial. The pattern of lymph node spread may differ between right-sided and left-sided tumors. Lymphatic drainage typically occurs via two main routes: hepatoduodenal and cardinal. The cardinal route is more common in left-sided tumors or tumors 5 cm.

We present a video of a 38-year-old woman with a single 6 cm intrahepatic cholangiocarcinoma in the left liver. The multidisciplinary team chose upfront resection, including a left hemihepatectomy with lymphadenectomy along both the hepatoduodenal and cardinal routes. A robotic approach was proposed, and consent was obtained.

The total operative time was 195 minutes, with minimal blood loss. The Pringle maneuver was used intermittently for 33 minutes. Recovery was uneventful, and the patient was discharged on postoperative day 4. Pathology revealed a single intrahepatic cholangiocarcinoma, 6 cm in size, with free margins, stage T2N0. A total of 25 lymph nodes were removed: 16 from the hepatoduodenal area and 9 from the cardinal dissection. The patient remains well, with no signs of disease 2 years after the procedure.

In left-sided intrahepatic cholangiocarcinoma, multiple routes of lymph node spread exist, and cardinal dissection should be considered, especially in larger tumors. When performed adequately, it does not increase morbidity and can be safely accomplished with the robotic platform during liver resection. This video may assist oncologic surgeons in performing this complex procedure.