Robot-assisted Radical Resection of Perihilar cholangiocarcinoma with Bovine Pericardial Patch Venoplasty

Objective To report the feasibility and technical details of robot-assisted radical resection of perihilar cholangiocarcinoma with portal vein wedge resection and bovine pericardial patch venoplasty. Methods A 59-year-old woman with obstructive jaundice was diagnosed preoperatively with Bismuth-Corlette type IIIb perihilar cholangiocarcinoma, with involvement of the left portal vein and portal vein confluence. According to the institutional vascular involvement classification, the lesion was categorized as PV2/HA0. Following percutaneous transhepatic biliary drainage and three-dimensional liver volumetric assessment, the patient underwent entirely robotic regional lymphadenectomy, extended left hepatectomy with caudate lobectomy, extrahepatic bile duct resection, portal vein wedge resection, bovine pericardial patch venoplasty, and intracorporeal Roux-en-Y hepaticojejunostomy with two biliary-enteric anastomoses. Results Intraoperative exploration demonstrated biliary extension consistent with Bismuth-Corlette type IV disease. The procedure was completed entirely robotically without conversion. The operative time was 550 min, including 25 min of robotic docking. Parenchymal transection, portal vein reconstruction, and biliary reconstruction required 69, 20, and 58 min, respectively. The total portal vein clamping time was 71 min. Estimated blood loss was 500 mL, and the patient received 2 units of packed red blood cells and 1.9 units of fresh frozen plasma. Histopathological examination confirmed moderately differentiated adenocarcinoma invading the full thickness of bile duct wall, adjacent liver parenchyma, perineural tissues and the lateral wall of the portal vein. All surgical margins were negative, confirming an R0 resection. Five of the 9 examined regional lymph nodes showed metastatic involvement. The final pathological stage was pT3N2M0, corresponding to stage IVA according to the AJCC 8th edition. Postoperative Doppler ultrasonography and contrast-enhanced computed tomography confirmed portal vein patency. A controlled bile leak classified as an International Study Group of Liver Surgery grade B bile leak and Clavien-Dindo grade II complication, resolved with conservative management within 3 weeks. Conclusion Robot-assisted radical resection of perihilar cholangiocarcinoma with bovine pericardial patch venoplasty is technically feasible in selected patients. Given the complexity of hilar dissection, vascular repair, and biliary reconstruction, this approach should be limited to high-volume hepatobiliary centers with extensive robotic and vascular experience.