Laparoscopic Right Hemi-hepatectomy Plus Total Caudate Lobectomy with Portal Vein Resection and Reconstruction for...

Hepatectomy combined with portal vein resection and reconstruction (PVR) is an option to achieve an R0 resection for perihilar cholangiocarcinoma (pCCA) with portal vein involvement.¹ However, this procedure still remains technically challenging, especially under laparoscopy.² We present a case of laparoscopic right hemi-hepatectomy plus total caudate lobectomy and PVR for Bismuth-Corlette type IV pCCA.

A 65-year-old female was admitted to our department after 1 week of escalating jaundice and abdominal pain. Preoperative imaging suggested Bismuth-Corlette type IV pCCA involving right anterior portal vein (RAPV). In three-dimensional reconstructed model, a virtual hepatectomy was performed to assess the hilar vascular anatomy and hepatic bile duct patterns³ (Fig. 1A and B). The right hemi-hepatectomy plus total caudate lobectomy and PVR was scheduled (Fig. 1C and D). Following resection of the extrahepatic bile ducts and dissection of regional lymph nodes, the tumor invasion of RAPV was confirmed intraoperatively. The cutting plane was determined by the indocyanine green (ICG) boundary of bile-duct obstructed area and the middle hepatic vein trunk.⁴ Without the full mobilization of liver, the liver parenchymal transection along the ICG boundary was performed until the left hepatic bile duct was transected. This maneuver provided a wider surgical field, facilitating safe PVR. The main portal vein (MPV) and left portal vein (LPV) were occluded with vascular clamps and sharply severed with scissors. Then, an end-to-end vascular anastomosis between MPV and LPV was performed by using continuous sutures of 5-0 Prolene. Finally, Roux-en-Y hepaticojejunostomy was fashioned to the left hepatic bile duct to allow for biliary drainage from the future liver remnant.

The operation was completed in 450 min with a blood loss of 200 mL. The final pathological diagnosis was cholangiocarcinoma with negative resection margin.

Laparoscopic right hemi-hepatectomy plus total caudate lobectomy with PVR is effective and feasible for selected patients with Bismuth-Corlette type IV pCCA.