Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Cancer Research Building #524, 59 Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, South Korea.
J Gastrointest Surg. 2019 Sep;23(9):1947-1948. doi: 10.1007/s11605-019-04242-9. Epub 2019 Jun 13.
Combined hepatic resection and pancreaticoduodenectomy is the treatment of choice for patient with extensive horizontal-spreading cholangiocarcinoma involving both the perihilar bile duct and the intrapancreatic distal bile duct. This surgical procedure is extremely complex, and incurs a high risk of postoperative morbidity and mortality. However, in recent years, this complicated high-risk operation can be safely performed in well-selected patients. However, as we know, none of these operations have been reported as minimally invasive surgery.
A 73-year-old female presented with jaundice and was diagnosed with cholangiocarcinoma. The preoperative image studies revealed a 4.3-cm-long diffuse, infiltrative cholangiocarcinoma from the hilar bile duct to the intrapancreatic bile duct without major vascular invasion. The patient was scheduled to undergo left hepatectomy with caudate lobectomy and pancreaticoduodenectomy to obtain a free resection margin. In order to maximize the efficiency of each surgical modality, we designed a hybrid method of laparoscopic resection and robotic reconstruction for this complicated surgery with a long operation time. A 12-mm port was placed at the subxiphoid area, which was utilized for laparoscopic CUSA during the liver resection. Three 12-mm ports around the umbilicus and an 8-mm robotic port at the right flank were placed. In the resection phase, pancreaticoduodenectomy was performed first, followed by hilar dissection and liver resection in en bloc manner. Here, a hanging maneuver was helpful for the complete resection of the caudate lobe in environment with the large specimen attached. In reconstruction phase, the right flank 8-mm port and the left side 12-mm port (using the double docking technique) were used for docking of two robotic working arms.
The total operation time was 510 min, and the estimated blood loss was 350 mL without transfusion. The patient's postoperative recovery was smooth, except for a mild fever due to cystitis, and she was discharged on the 16th postoperative day. Permanent pathologic examination revealed a disease-free proximal bile duct margin, but a metastasis was discovered in one regional lymph node metastasis from 18 retrieved lymph nodes. The patient is receiving adjuvant gemcitabine chemotherapy and regular surveillance. We performed two consecutive cases and the perioperative outcomes were summarized in the attached video.
Hepatopancreaticoduodenectomy has a long operative time, involves complicated anatomical structures and difficulty of R0 resection, and it is a remaining frontier of minimally invasive surgery. However, we expect that highly selected patients can carefully undergo minimally invasive surgery if the advantages of the currently available surgical methods are well utilized.
对于累及肝门部胆管和胰内远端胆管的广泛横向扩展型胆管癌患者，联合肝切除术和胰十二指肠切除术是治疗的首选方法。这种手术非常复杂，术后发病率和死亡率很高。然而，近年来，这种复杂的高危手术可以安全地应用于选择合适的患者。但是，正如我们所知，这些手术都没有被报道为微创手术。
一名 73 岁女性因黄疸就诊，被诊断为胆管癌。术前影像学研究显示，从肝门胆管到胰内胆管有一条 4.3 厘米长的弥漫性浸润性胆管癌，无主要血管侵犯。患者计划接受左半肝切除术、尾状叶切除术和胰十二指肠切除术，以获得无肿瘤残留的切缘。为了最大限度地提高每种手术方式的效率，我们为这例手术时间长的复杂手术设计了一种腹腔镜切除和机器人重建的混合方法。在剑突下区域放置一个 12mm 的端口，用于肝切除过程中的腹腔镜 CUSA。在脐周放置三个 12mm 的端口和右侧肋缘下一个 8mm 的机器人端口。在切除阶段，首先进行胰十二指肠切除术，然后整块进行肝门部解剖和肝切除术。在这里，悬挂操作有助于在附着大标本的环境中完全切除尾状叶。在重建阶段，使用右侧肋缘下 8mm 端口和左侧 12mm 端口（使用双对接技术）对接两个机器人工作臂。
总手术时间为 510 分钟，估计失血量为 350ml，无需输血。患者术后恢复顺利，除因膀胱炎导致轻度发热外，于术后第 16 天出院。永久性病理检查显示近端胆管切缘无肿瘤残留，但在 18 个检出的淋巴结中发现 1 个区域淋巴结转移。患者正在接受吉西他滨辅助化疗和定期随访。我们连续完成了两例手术，并将围手术期结果总结在附加视频中。
肝胰十二指肠切除术手术时间长，涉及复杂的解剖结构和难以达到 R0 切除，是微创手术的一个尚未解决的难题。然而，如果能够充分利用目前可用的手术方法的优势，我们预计可以为高度选择的患者进行谨慎的微创手术。
