Robotic-Modified Taj Mahal Hepatectomy for Type IV Hilar Cholangiocarcinoma

Curative resection of type IV hilar cholangiocarcinoma typically requires trisectionectomy, a procedure associated with high morbidity. The Taj Mahal hepatectomy, involving resection of segment IVb, V, and the caudate lobe, offers a parenchyma-preserving alternative.¹ Since complete resection of segment IV facilitates caudate lobectomy, and inclusion of segment V provides no added benefit, a modified approach-removing only segment IV (IVa and IVb) with the caudate lobe-has been developed.² The robotic performance of this modified procedure has not been reported previously in the English literature. This video demonstrates the standardized technique of robotic-modified Taj Mahal hepatectomy for type IV hilar cholangiocarcinoma.

Patients with type IV hilar cholangiocarcinoma without vascular involvement are suitable candidates. A 59-year-old male with jaundice and 1-month weight loss underwent sequential percutaneous transhepatic biliary drainage (segment III and right posterior ducts) for elevated bilirubin (>30 mg/dL). Key steps included hepatoduodenal lymphadenectomy, distal bile duct division with frozen section, caudate mobilization via a left-sided approach, indocyanine green-guided segment IV resection with en bloc caudate lobectomy, and three separate cholangiojejunostomies.

Operative time was 560 minutes with 300 mL blood loss. The postoperative course was uneventful, and the patient was discharged on day 8. Histopathology showed T2 moderately differentiated adenocarcinoma with negative margins and 14 tumor-free lymph nodes. At 11-month follow-up, the patient remained disease free. Four patients underwent this procedure over 12 months.

Robotic-modified Taj Mahal hepatectomy is a safe, feasible, parenchyma-preserving option for selected patients with type IV hilar cholangiocarcinoma.