Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer in humans after hepatocellular carcinoma, with an incidence of 0.3–3.36 new cases every 100,000 yearly in western countries (1). Differently from hepatocellular carcinoma, whose risk factors are well known and also related to the geographic distribution (2), ICC’s risk factors are less recognized. Some of these include the presence of intrahepatic biliary stones and primary sclerosant cholangitis (3). ICC’s growth is often silent and weaselly, with the possibility of reaching huge dimension at the moment of the diagnosis, making about half of the patients affected by ICC not suitable for surgery with curative intents. ICC’s prognosis is dismal as well, with a mortality at 3 months for advanced cases (4), and a 5-year survival which is inferior to 40%.
The resectability of patients affected by ICC is determined by the possibility to obtain R0 margin through liver surgery. For ICC, this often means requiring major liver resection. Furthermore, the role of LND is well recognized, indeed a “formal lymphadenectomy” is recommended not just to complete the staging of the disease, but also to limit the possibility of a tumor spread through the lymphatic system. The previous two arguments made laparoscopy to be historically poorly applied in treating cholangiocarcinoma, both for the needing of major hepatectomies and for the necessity of performing formal lymphadenectomies.
The aim of this review is to investigate the extension and the diffusion of the use of laparoscopy applied to surgical treatment of ICC, beside to furnish technical notes to conduct safe liver resection and LND for ICC.
We conducted a literature search using PubMed, screening all English publications on laparoscopic (LPS) liver resection for ICC. The following keywords were used to identify articles relevant to our study: “laparoscopic cholangiocarcinoma”, “laparoscopic intrahepatic biliary cancer”.
Through the described keywords, we identified 11 studies encompassing both small series and case reports from institutions which approached ICC laparoscopically with curative intents (Table 1). Five more papers were identified, which are relative to the importance of diagnostic laparoscopy as a staging tool, but without any mention of a minimally invasive treatment of ICC through LPS surgery.
Exclusion criteria of patients affected by ICC from LPS programs may be addressed to the disease’s features themselves, which constitute a relative contraindication for the presence of technical challenges: firstly, huge resections requiring vascular or biliary reconstructions, and, secondly, the necessity to guarantee an adequate LND, which is nowadays recommended by the European Association for the Study of the Liver guidelines (1) for the treatment of ICC.
As laparoscopy is currently poorly applied to the treatment of ICC, data regarding this pathology are often included in casuistries encompassing both primary and secondary liver diseases, with scarce specificity to ICC. Nevertheless, we would point out the reasons capable of affecting the feasibility of laparoscopy for ICC, that we assume being three: the needing to convert to open surgery, the post-operative morbidity and the role of LPS LND.
Conversion to open surgery
Among the 11 studies we identified, 5 presented the conversion rate to open surgery and the reasons for conversion. Of these, 3 studies (5-7) are miscellaneous case series that encompass just few LPS resections for ICCs (range, 1.8–4%). This small portion of LPS resections for ICCs is also aligned to the bigger casuistry collected by Aldrighetti et al. in a national survey (8), whereas on a sample of 1,497 LPS resections, 4.1% were executed for ICCs.
In Table 2, we reported the conversion rate and we analysed the reasons that took authors to convert to open surgery.
Among the 1,882 cases included in the studies we analyzed, there were 206 (10.9%) conversions to open surgery. Of these, the main reason were intraoperative hemorrhages (35.9%), followed by technical difficulties (32%) encompassing adhesions from previous surgery, hollow viscous injuries or toughness related to inadequate exposition and managing through laparoscopy. Another quarter of the causes of conversion were due to concerns to achieve oncological radicality (25.7%), whereby a LPS management would not have allowed R0 margins under safe circumstances. It should be bear in mind that these data are relative to spurious casuistries, not specific for ICCs, although if it is likely they embody also the reality of the LPS treatment of cholangiocarcinoma.
Although the exiguity of the samples, the LPS technique didn’t show any significant variances in terms of increasing post-operative morbidity, witnessing the applicability and the feasibility of the minimally invasive technique also in ICC’s treatment.
The role of LND
Among the six studies that discussed the role of LND (Table 4), Wang et al. (12) considered the needing of a LND as exclusion criteria to perform the operation laparoscopically due to the difficulty of achieving R0 resections. On the other side, few authors performed LND laparoscopically, proving performing LPS LND didn’t constitute an element of increased morbidity in comparison to not doing it or compared to the lymph nodes harvesting in open surgery (9), thereby demonstrating LPS LND should not contraindicate the minimally invasive approach.
As we described, surgery for ICC requires both a hepatic transection which were oncologically correct achieving R0 margins, associated to a LND. These criteria belonging to open surgery must be applied to the LPS procedures as well, in the purpose of guarantee the adequate principles of oncologic validity.
Our intent is to describe technical issues regarding both LPS LND and the hepatic transection.
Under general anesthesia, using the LPS French position with the first operator between the patient’s legs and having the first and the second assistant respectively on the left and on the right side of the patient, five LPS ports are placed in a standardized fashion drawing an “inverted J” on the patient’s abdomen (Figure 1).
We routinely adopt a slightly modified French position for any kind of liver resection, having both the knees and the hips lightly bent thus allowing a better and safer reverse Trendelenburg tilting. Both arms are kept opened to increase the patient stability, to allow a better anesthesiologic management and to reduce the risk of involuntarily injuries to upper arms and hands (Figure 2). A pneumatic heaver under the right hemicostate on the back can be inflated as needed to allow better achieving of posterior and superior segments.
After prepping and draping, a Rochard’s retractor is always placed to allow a faster conversion to open surgery in case of necessity.
Pre-resective assessment is completed intraoperatively through an accurate US using the LPS probe, in order to confirm the operability in an R0’s target.
As we consider the LPS LND a demanding surgical time, which requires an advanced LPS training, we prefer performing it as the first surgical time, before proceeding with the hepatic transection.
The LND is guided by an accurate preoperative CT evaluation, which allows clearly to identify the celiac tripod, the origin or the common hepatic artery and its right and left branches, and possible accessory branches coming from the left gastric artery and/or from the superior mesenteric artery. Finally, particular attention should be also paid to the anatomy and to anatomic variations of common portal trunk, with particular carefulness to extraparenchimal “early” origin of left or right portal branches.
“Formal lymphadenectomy” of ICC encompasses the complete removal of lymph node station 8 (on the common hepatic artery) and 12 (encompassing regional nodes 12a along the hepatic artery, 12b along the bile duct and 12p behind the portal vein) (Figure 3).
A possible extension to station 13 (lymph nodes on the posterior surface of the pancreatic head) is possible if the preoperative workup (CT and/or MRI) is consistent with a severe lymphadenopathy involving that region.
We start lymph nodes dissection at the celiac tripod, detecting the origin of the common hepatic artery, and it should be conducted up to completely skeletonizing the common hepatic artery (Figure 4), upon its entrance into the hepatoduodenal ligament.
We believe the utilization of a device both capable of sealing and cutting contemporaneously were particularly useful in this phase, alternatively using the hook and bipolar forceps for a particularly precise dissection. During this time of dissection, it is particularly important also recognize the left gastric artery arising from the celiac tripod, avoiding to interrupt or to damage possible accessory arteries deriving from it that may be directed to the left hepatic lobe, if this is not in accordance with the planned liver resection.
Once obtained a complete LND of the common hepatic artery, the aim of LND is to obtain a complete removal of the lymphatic tissue encompassed into the hepatoduodenal ligament, in order to complete the harvesting of the entire station 12. The dissection should be particularly precise at this time as well, in order to avoid any injury to the common bile duct, to the right and left branches of the hepatic artery and to the portal trunk (Figure 5).
Once the LND of the hepatic pedicle is completed, the following surgical time is constituted by the hepatic transection.
Before any kind of hepatic transection, with the exception constituted by superficial nodulectomy and by the left lateral sectionectomy, we retain the placement of a Pringle’s manoeuver as a must in order to have a vascular control to avoid any major bleeding during both open and LPS resections. However, we think the placement of a Pringle’s manoeuver in a standard fashion by using an umbilical lace and a tourniquet, should be avoided in cases where the vessel’s walls are exposed as a result of the LND. We recommend, instead, the use of LPS clamps for selective portal and arterial intermittent clamping, alternating 10 minutes of ischemia to 5 minutes of reperfusion. Once confirmed the resection’s limits through US, the transection is performed by using an ultrasound dissector, exposing vascular structures which are selectively coagulated by bipolar forceps or sealed through clips or staplers, according to dimension.
Short term outcome
Although the lack of data specific for ICC showed in feasibility, we retain the 3 limiting factors (conversion to open, morbidity, LPS LND) might be overtaken and tackled in the contest of an advanced LPS skills. Particularly, the conversion rate of 10.9% is comparable to the overall conversion rate to open for other advanced LPS procedures.
We could not identify neither significant differences in terms of morbidity between open and LPS surgery for ICC. In favour of this, there might be a particular attention to the selection of cases, aimed in candidate to laparoscopy cases of ICCs with a not widely extended disease. To our knowledge, the most important series of patients affected by ICC was recently described by Ratti et al. (9), with a 7.6% (20/266) of patients treated laparoscopically on a consecutive series who were affected by ICC, whereas the national average presented in an Italian survey was 4% (45/1,085) of the total of patients treated for malignant tumors (8). In their series, Ratti et al. demonstrated morbidity was similarly low and comparable between the LPS group and the open one; additionally, patients belonging to the LPS group showed a faster functional recovery, as a result of an inferior biologic stress.
Knowledges relative to lymph nodes retrieving are even rarer. Few authors consider LND as a contraindication to approach cases laparoscopically due to technical difficulties. Others, instead, consider LPS LND feasible, with similar results in terms of number of lymph nodes retrieved compared to open, without causing any increasing in morbidity.
Long term outcome
Among the two case series which assessed the role of LPS for ICCs, having a group of open resection as control one, there wasn’t any statistically significant difference between the two groups in terms of disease free survival and on the 3-year overall survival (9,11).
Despite the dramatic improvements of LPS technologies and their extensive application to treatment of primary and secondary, either benign or malignant liver diseases, still few cases of ICC receive a minimally invasive treatment.
Although the lack of data in the literature, we believe application of LPS to ICC is safe due to a comparable conversion rate respectful to other major LPS liver resections, and because it did not show any increasing of morbidities in the examined series. Furthermore, it is effective, as long term results were equal to those deriving from open surgeries. Though LPS LND is technically challenging, we described it is feasible as well, by conducting an accurate preoperative assessment aimed to identify the vascular anatomy and its variations. Furthermore, LPS LND is not cause of increased morbidity.
We wish laparoscopy could soon join the standard of care for resective liver surgery and LND for ICC, in order that those patients also might benefit of advantages deriving from minimally invasive surgery.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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Cite this article as: Fiorentini G, Ratti F, Cipriani F, Palombo D, Catena M, Paganelli M, Aldrighetti L. Minimally invasive approach to intrahepatic cholangiocarcinoma: technical notes for a safe hepatectomy and lymphadenectomy. Ann Laparosc Endosc Surg 2017;2:68.