Robotic surgery for perihilar cholangiocarcinoma is in the developmental and exploratory phase. The objective of this study was to compare the short-term outcomes and survival rates of robotic versus open resection for perihilar cholangiocarcinoma in a single center, and to determine the reliable scope of robotic interventions.

A comparative analysis of outcomes from open and robotic resections at a single center was conducted using propensity score matching (PSM). The balance of covariates was assessed using standardized mean differences, and the robotic resection procedures adhered to the standards of open surgery.

PSM was effectively applied between 41 robotic and 82 open resections. No differences were observed in blood loss, overall and severe morbidity, 90-day mortality, or length of hospital stay. Robotic resections were longer but resulted in better immediate oncological outcomes. Median overall survival for the robotic and open groups was 44 and 30 months (p = 0.259) before PSM and 44 and 29 months (p = 0.164) after PSM respectively. Conversion was required in 8 cases. A subgroup analysis excluding conversions revealed no differences in immediate and long-term outcomes. All patients undergoing robotic resection for Bismuth types I and II were alive at a mean follow-up of 37 months.

The robotic approach is comparable to open resection regarding immediate outcomes and survival in select patients with perihilar cholangiocarcinoma. For patients with Bismuth type I and II tumors and early (stages I and II) TNM stages, robotic resection is a reliable treatment option when aligned with the principles of open surgery.

To examine the feasibility and safety of robotic radical resection (RRR) for hilar cholangiocarcinoma (HCCA). A PRISMA-compliant meta-analysis with meta-regression was conducted, including studies reporting outcomes of RRR in patients with HCCA. Six studies comprising 295 patients were included. In highly selected patients (body mass index [BMI] < 25 kg/m" ; tumor size < 3 cm), RRR of HCCA proved safe and feasible (Clavien-Dindo ≥ III complications: 14.8% [95% confidence interval 8.7%-20.8%]; 30-day mortality: 1.9% [0%-4.2%]; conversion to open surgery: 1.9% [0%-4.2%]; intraoperative blood loss: 210 mL [119-301 mL]; operative time: 481 minutes [339-623 minutes]; R0 resection rate: 82.2% [75.0%-89.4%]; retrieved lymph nodes: 12 [9-16]). Younger age (p = 0.008), higher BMI (p = 0.009), larger tumors (p = 0.048), and performing liver resections (p = 0.017) increased blood loss. American Society of Anesthesiologists status ≥ III (p < 0.001) and Bismuth IV disease (p < 0.001) increased operative times. Preoperative biliary drainage (p = 0.027) enhanced R0 resection rates. RRR led to less bleeding (mean difference [MD]: -184 mL, p = 0.0005), longer operative times (MD: 162 minutes, p = 0.001), and improved R0 resection rates (odds ratio: 3.29, p = 0.006) compared with the open approach. Subject to selection bias and type 2 error, RRR for HCCA might be safe and feasible in highly selected patients (favorable BMI and tumor size). The findings should not be taken as definitive conclusions but may be used for hypothesis generation in subsequent trials.

Extended right hepatectomy (ERH) for hilar cholangiocarcinoma (HCCA) is a complex procedure associated with a high risk of postoperative complications. We present a case of ERH complicated by a biliary fistula at the hepatico-jejunostomy site, which led to a severe anastomotic stricture. Traditional percutaneous transhepatic drainage repeatedly failed in this case. The stricture was ultimately treated with trans-jejunal metal stent insertion, successfully restoring bilio-enteric drainage. A 62-year-old male patient was diagnosed with HCCA. After staging, he underwent liver vein deprivation to augment the future liver remnant (FLR), followed by curative resection via ERH (segments I and IV-VIII). Postoperatively, a bile leak at the anastomotic site resulted in a bilio-cutaneous fistula. While conservative management led to a gradual resolution, the fistula caused a tight anastomotic stricture, leading to obstructive jaundice. Traditional percutaneous transhepatic drainage attempts repeatedly failed to traverse the lengthy stricture. Consequently, a novel procedure of inserting a metal biliary stent via a percutaneous puncture of the jejunal loop was attempted. Under CT guidance, the Roux loop was catheterized and distended with contrast, and a guidewire was positioned inside. The patient was then transferred to the angiography suite. Under fluoroscopy, a transjugular intrahepatic portosystemic shunt needle punctured the bile duct stump, providing access to the Roux loop. A fully covered metal stent was successfully deployed crossing the anastomosis re-establishing bilio-enteric drainage. This novel radiological intervention salvaged the remnant liver when standard approaches had failed. Hepatico-jejunostomy stricture following ERH is a critical postoperative complication that can severely compromise FLR function. Surgical options in such cases are limited and pose significant risks. Radiological intervention offers a promising alternative, enabling effective drainage even in the most challenging postoperative scenarios.

Hilar cholangiocarcinoma, a rare and aggressive bile duct malignancy, presents significant challenges in surgical management. Traditionally treated with open surgery, the emergence of robotic surgery has introduced a new dimension to surgical approaches for this condition. This review aims to systematically compare the efficacy and safety of robotic surgery versus open surgery for hilar cholangiocarcinoma. We conducted a comprehensive review of the literature, including clinical studies, case series, and comparative analyses of robotic and open surgical techniques. Data on oncological outcomes, functional recovery, survival rates, complications, and cost-effectiveness were extracted and analyzed to provide a detailed comparison of the two surgical approaches. Robotic surgery offers several potential advantages over open surgery, including reduced intraoperative blood loss, smaller incisions, and shorter recovery times. However, it requires specialized training and has a higher initial cost. Open surgery, while more established and broadly practiced, remains associated with longer recovery periods and higher complication rates. Oncological outcomes, such as R0 resection rates and survival, appear comparable between the two approaches, though robotic surgery may offer improvements in functional recovery and postoperative quality of life. Both robotic and open surgery have their merits in the treatment of hilar cholangiocarcinoma. Robotic surgery presents promising benefits in terms of reduced invasiveness and improved recovery, while open surgery continues to be a reliable and well-established option. The choice of surgical approach should be guided by patient-specific factors, surgeon expertise, and institutional resources. Further research is needed to refine surgical techniques and establish long-term outcomes, which will aid in optimizing treatment strategies for this challenging malignancy.

In recent years, pure laparoscopic radical surgery for Bismuth-Corlette type III and IV hilar cholangiocarcinoma (HCCA) has been preliminarily explored and applied, but the surgical strategy and safety are still worthy of further improvement and attention.

To summarize and share the application experience of the emerging strategy of "hepatic hilum area dissection priority, liver posterior separation first" in pure laparoscopic radical resection for patients with HCCA of Bismuth-Corlette types III and IV.

The clinical data and surgical videos of 6 patients with HCCA of Bismuth-Corlette types III and IV who underwent pure laparoscopic radical resection in our department from December 2021 to December 2023 were retrospectively analyzed.

Among the 6 patients, 4 were males and 2 were females. The average age was 62.2 ± 11.0 years, and the median body mass index was 20.7 (19.2-24.1) kg/m2. The preoperative median total bilirubin was 57.7 (16.0-155.7) μmol/L. One patient had Bismuth-Corlette type IIIa, 4 patients had Bismuth-Corlette type IIIb, and 1 patient had Bismuth-Corlette type IV. All patients successfully underwent pure laparoscopic radical resection following the strategy of "hepatic hilum area dissection priority, liver posterior separation first". The operation time was 358.3 ± 85.0 minutes, and the intraoperative blood loss volume was 195.0 ± 108.4 mL. None of the patients received blood transfusions during the perioperative period. The median length of stay was 8.3 (7.0-10.0) days. Mild bile leakage occurred in 2 patients, and all patients were discharged without serious surgery-related complications.

The emerging strategy of "hepatic hilum area dissection priority, liver posterior separation first" is safe and feasible in pure laparoscopic radical surgery for patients with HCCA of Bismuth-Corlette types III and IV. This strategy is helpful for promoting the modularization and process of pure laparoscopic radical surgery for complicated HCCA, shortens the learning curve, and is worthy of further clinical application.

With the increasing efficacy of systemic therapy, liver transplantation plays an important role not only for hepatocellular carcinoma (HCC) but also for nonresectable intrahepatic cholangiocellular carcinoma (iCC), perihilar cholangiocellular carcinoma (phCC) and colorectal liver metastases (CRLM).

To review the current state of knowledge regarding the indications, patient selection and expected outcomes of liver transplantation for HCC, iCC, phCC and CRLM.

When combined with neoadjuvant locoregional therapy (LRT) and/or systemic therapy, patients with nonresectable HCC, iCC, pCC and CRLM confined to the liver can be successfully transplanted with 5‑year survival rates exceeding 65%. The key to success is strict patient selection, which includes oncogenetic (e.g., BRAFV600E mutation status) and clinical criteria indicative of individual tumor biology (tumor markers: alpha-fetoprotein, AFP/carbohydrate antigen 19‑9, CA19-9/carcinoembryonic antigen, CEA, stable response to neoadjuvant therapy) in addition to morphometric criteria.

Liver transplantation offers the possibility of curative treatment even for nonresectable hepatic malignancies. A major limitation of this treatment is the lack of donor organs. Crucial for success is patient selection based on individual tumor biology.