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.

Hilar cholangiocarcinoma (HCCA) is a malignant bile duct epithelial tumor originating from the common hepatic duct, left and right hepatic ducts and conjunctures and accounts for approximately 50%-70% of cholangiocarcinomas[1]. HCCA is difficult to diagnose in the early stage, and patients’ prognosis is poor. Surgical resection remains the only curative treatment option for HCCA[2]. Due to the complex anatomical structure of the hepatic hilum, the variation rate of the bile duct and blood vessels is high. In particular, for Bismuth-Corlette type III and IV patients, the tumor invaded the hepatic duct, left and right hepatic ducts and secondary bile duct. Patients often exhibit hepatic artery (HA), portal vein, intrahepatic and extrahepatic bile duct invasion and intrahepatic duct variation. As a result, the surgical resection rate is low, and the incidence rates of postoperative complications and mortality are relatively high[3]. At present, patients with HCCA of Bismuth-Corlette types III and IV usually undergo radical operations via open surgery. In recent years, with the development of the concept and technology of the laparoscopic technique, pure laparoscopic radical surgery for Bismuth-Corlette type III and IV HCCA has also been preliminarily explored and applied, but the surgical strategy and safety are still worthy of further improvement and attention[4,5].

In recent years, on the basis of long-term clinical practice, our team summarized the surgical strategy of “hepatic hilum area dissection priority, liver posterior separation first” for the pure laparoscopic radical surgical procedure for patients with Bismuth-Corlette type III and IV HCCA. To date, this strategy has achieved good surgical results in clinical application, and the relevant clinical data and surgical video analyses are summarized.

Radical surgery for HCCA has always been a difficult problem in the field of hepatobiliary and pancreatic surgery. As complicated anatomical structures are involved in HCCA, surgeons are must be aware of the vasculature adjacent to the tumor during the operation. Therefore, surgery for HCCA is difficult, and the risk of postoperative complications is high[8]. In particular, due to wider tumor involvement and more complicated anatomical structures, radical surgery is more difficult in patients with HCCA of Bismuth-Corlette types III and IV[5]. The main characteristics of the types of tumors are as follows: (1) There is a high risk of local aggression: Bismuth-Corlette types III and IV HCCA are usually highly invasive and often invade surrounding vital blood vessels and tissues, which significantly increases the difficulty of the operation[9]; (2) A high proportion of lymph node metastasis: Patients with HCCA of Bismuth-Corlette types III and IV have a relatively high risk of lymph node metastasis, which may lead to a high risk of postoperative recurrence and metastasis. Therefore, thorough lymph node dissection is essential for these patients[10]. It is particularly important to optimize the technology used for modular and en bloc clearance of the hepatic hilar region[11,12]; (3) A high rate of surgical margin positivity: Due to the particularity of the tumor location and invasiveness, the rate of surgical margin positivity is relatively high in Bismuth-Corlette type III and IV HCCA patients, which further increases the risk of postoperative recurrence[13,14]; and (4) A high risk of intraoperative bleeding: Due to the extensive vascular network in the hepatic hilar area, complex anatomical variation factors, and the requirement for extensive hepatectomy, the risk of intraoperative bleeding is high[15,16]. Therefore, strict intraoperative vascular protection and control are essential in Bismuth-Corlette type III and IV HCCA patients.

In recent years, with the continuous development of laparoscopic surgery concepts and technology, pure laparoscopic radical surgery for HCCA has gradually attracted the attention of surgeons. Laparoscopic technology has the advantages of a surgical field amplification effect and unique perspective, which can make surgical operation more accurate, especially when operating on the posterior side of various tissues and organs[17]. However, for patients with HCCA of Bismuth-Corlette types III and IV, there are still some challenges and difficulties in the selection of radical laparoscopic surgery strategies and surgical safety[5,18]. Extensive experience in laparoscopic surgery and sufficient technical reserve are the basic requirements for surgeons[19]. Therefore, to date, this type of operation has only been explored and studied in a few experienced high-level medical centers.

In view of the above surgical difficulties, our team has summarized surgical strategies for “hepatic hilum area dissection priority, liver posterior separation first” for long-term clinical practice. The clinical application of this surgical strategy resulted in satisfactory curative effects in 6 patients. All 6 patients successfully completed the operation, and compared with previous reports of similar operations, the application of this strategy could shorten the operation time, reduce intraoperative blood loss, and shorten the postoperative hospital duration[20]. In addition, none of the patients experienced serious perioperative complications. Postoperative follow-up further revealed that the operative effect was satisfactory, and the quality of life significantly improved. Therefore, this surgical strategy is safe and feasible in surgical practice and has important clinical significance for optimizing surgical procedures and improving treatment efficacy and quality of life.

Briefly, there are several advantages of this strategy. First, this technical strategy focuses on priority exploration and dissection of the hepatic hilar region, which is favorable for accurately evaluating the resectability of tumors during surgery and preventing unnecessary surgical trauma. In addition, the priority clearance of the hepatic hilar region is favorable for the distinction and protection of vital blood vessels in the hilar region, which is conducive to the disconnection or blocking of hepatic blood vessels during subsequent hepatectomy[21]. Therefore, this strategy reduces the risk of intraoperative bleeding and complications and improves the safety of surgery[21]. Second, the strategy is preferred for en bloc clearance in the hepatic hilar region, which improves the effectiveness of radical surgery, prevents tumor residue and reduces postoperative recurrence risk[22]. In addition, the adoption of the strategy of posterior liver separation can fully exploit the advantages of laparoscopy, and surgeons can address the short hepatic vein behind the liver in advance, which is not easy to reveal from a conventional perspective and is prone to accidental bleeding. The release of the space behind the liver is conducive to subsequent extended hepatectomy combined with caudate lobectomy. In addition, it reduces intraoperative bleeding and improves the radical excision rate and safety of the operation[23]. Finally, the implementation of this strategy helps to modularize and streamline the entire surgical procedure to shorten the surgical time, reduce intraoperative bleeding, and improve the surgical completion rate. Therefore, laparoscopic radical surgery is expected to become the preferred strategy for patients with HCCA of Bismuth-Corlette types III and IV.

Although this study has yielded some profound findings, there are still several shortcomings. First, the sample size was relatively small, and it is necessary to further expand the sample size and carry out multicenter clinical research. Second, the applicability and effectiveness of this strategy for patients with different pathological types, surgeons with different levels of experience and patients at different medical centers should be further explored. Third, the follow-up period was too short to assess long-term outcomes. Long-term follow-up and assessment of postoperative quality of life are still needed to fully understand the long-term effects of this strategy.

In conclusion, the emerging strategy proposed by our team, “hepatic hilum area dissection priority, liver posterior separation first”, is safe and feasible for the pure laparoscopic radical surgery of 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 and for shortening the learning curve and is worthy of further clinical application.