New surgical procedure for perihilar cholangiocarcinoma: transhepatic hilar approach to confirm a negative margin of proximal bile duct first

Background: The most important factor for R0 resection for perihilar cholangiocarcinoma (PHC) is negative margin (NM) of the remnant liver, although surgical procedures can be performed in several ways. Our procedure, transhepatic hilar approach (THA), confirms a NM of proximal bile duct (BD) first (J Gastrointest Surg. 2016). This study aims to present THA procedure for PHC and outcomes. Methods: First of all, partial hepatic parenchymal transection to expose hilar plate is performed, followed by skeletonization of HA, PV, and BD in the remnant liver. Then, the proximal BD resection is performed to confirm a NM, followed by the distal BD resection and skeletonization of the hepatoduodenal ligament. Thereafter, the hepatectomy (Hx) with caudate lobe is completed. THA provides us with a clear surgical view to perform reconstruction of PV in the middle of Hx. We performed THA for 27 patients between 2011.1 and 2017.1, of whom 17 (63%) received preoperative chemotherapy. Results: There were left Hx in 13, trisectionectomy (TSN) in 2, right Hx in 9, TSN in 1, and others in 2. Vascular resection (PV in 12, HA in 1, PV and HA in 3) was performed in 16 (59%). R0 resection was achieved in 20 (74%). Clavien III or higher complications occurred in 13 (48%) without mortality. Five-year survival rate was 34% (MST:53M). Conclusion: THA can provide us with an opportunity to confirm a NM of proximal BD first and with a clear surgical view to easily perform reconstruction of PV in the middle of Hx, resulting in satisfactory outcomes.