Safety and feasibility of laparoscopic radical resection for bismuth types III and IV hilar cholangiocarcinoma: a single-center experience from China

Abstract

Background: Surgery represents the only cure for hilar cholangiocarcinoma (HC). However, laparoscopic radical resection remains technically challenging owing to the complex anatomy and reconstruction required during surgery. Therefore, reports on laparoscopic surgery (LS) for HC, especially for types III and IV, are limited. This study aimed to evaluate the safety and feasibility of laparoscopic radical surgery for Bismuth types III and IV HC.

Methods: The data of 16 patients who underwent LS and 9 who underwent open surgery (OS) for Bismuth types III and IV HC at Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, between December 2017 and January 2022 were analyzed. Basic patient information, Bismuth-Corlette type, AJCC staging, postoperative complications, pathological findings, and follow-up results were evaluated.

Results: Sixteen patients underwent LS and 9 underwent OS for HC. According to the preoperative imaging data, there were four cases of Bismuth type IIIa, eight of type IIIb, and four of type IV in the LS group and two of type IIIa, four of type IIIb, and three of type IV in the OS group (P>0.05). There were no significant differences in age, sex, ASA score, comorbidity, preoperative percutaneous transhepatic biliary drainage rate, history of abdominal surgery, or preoperative laboratory tests between the two groups (P>0.05). Although the mean operative time and mean intraoperative blood loss were higher in the LS group than in OS group, the differences were not statistically significant (P=0.121 and P=0.115, respectively). Four patients (25%) in the LS group and two (22.2%) in the OS group experienced postoperative complications (P>0.05). No significant differences were observed in other surgical outcomes and pathologic findings between the two groups. Regarding the tumor recurrence rate, there was no difference between the groups (P>0.05) during the follow-up period (23.9 ± 13.3 months vs. 17.8 ± 12.3 months, P=0.240).

Conclusion: Laparoscopic radical resection of Bismuth types III and IV HC remains challenging, and extremely delicate surgical skills are required when performing extended hemihepatectomy followed by complex bilioenteric reconstructions. However, this procedure is generally safe and feasible for hepatobiliary surgeons with extensive laparoscopy experience.

Keywords: caudate lobectomy; hilar cholangiocarcinoma; laparoscopy; radical resection; safety.

Figure 1

Flow chart of the study design and participant eligibility.

Figure 2

Trocar placement on the abdomen.

Figure 3

Typical Bismuth type IV HC patient who received laparoscopic radical resection. (A) Preoperative MRI image. The red arrow indicated where the tumor of bile duct was located. (B) Preoperative MRCP image. The red arrow indicated where the tumor was located. (C) Preoperative 3-D reconstruction model of the Bismuth type IV HC patient. The yellow area indicated by the red arrow was the tumor. (D) The hepatic hilum after central hepatectomy and extended lymphadenectomy. Skeletonized portal vein and hepatic artery were visible and the green arrow indicated the bile duct opening after central hepatectomy. (E) Biliary-intestinal anastomosis of the right hepatic duct section. (F) Biliary-intestinal anastomosis of the left hepatic duct section.