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Additional file 1. Â Supplementary Methods. File Format: PDF.

Additional file 1. Â Supplementary Methods. File Format: PDF.

Portal vein arterialization (PVA) in advanced cholangiocarcinoma (CCA) is an emerging field of study too little explored despite its potential oncological results. Still to this day, advanced CCA, including peri-hilar (pCCA) and distal (dCCA) CCA, represents a surgical challenge. At diagnosis, CCA is typically associated with extensive infiltration of hilar structures often requiring extended liver and vascular resections that lead to technically complex biliary reconstructions and vascular anastomosis. The rationale behind such radical surgery is to ensure complete tumor resection, with negative margins at final pathology, which remains the only potential curative option. In this scenario, we report a case of advanced CCA, originating from the cysto-choledocal junction, encasing the extrahepatic course of the right hepatic artery (RHA) in which right PVA was carried out to obtain free tumor margins. Considering the technical impossibility to perform a right trisectionectomy due to inadequate future remnant liver (FRL) volume, PVA represented a turning point in the surgical planning of the case. The encouraging postoperative clinical outcomes suggest that PVA should be considered as a valid rescue option to preserve liver inflow in case of locally aggressive HPB malignancies that require extensive resection of the hepatic artery or its branches. This surgical technique can offer an efficient solution in those cases in which the RHA cannot be reconstructed due to its caliber or due to an early subdivision into the right sectorial branches.

The magnification of images provided by minimally-invasive surgery (MIS) allows a very sharp and precise dissection of the hepatic hilum, allowing to overcome the technical complexity of surgery of perihilar cholangiocarcinoma (PHC). Recently, the feasibility and reproducibility of MIS for PHC are reported: within centers with adequate expertise and respecting the cornerstones of oncological adequacy, it provides short term advantages in a selected population of patients. The video reports the case of a patient with PHC involving the right biliary duct and requiring right hepatectomy with biliary confluence and segment 1 resection, with associated lymphadenectomy. Current evidences, together with feasibility and reproducibility of the technique shown in this video, appear promising and constitute a good prerequisite for the further implementation of this approach to improve patients outcome while following the principles of surgical oncology in hilar cholangiocarcinoma.

Background:At the end of a laparoscopic major hepatectomy, an incision wide enough for specimen retrieval is required. Classically, Pfannenstiel (PF) incision is the type of access favored as service incision in laparoscopy. However, in specific settings the use of a midline (ML) incision can be favorable, with doubtful impaction on the outcomes of a purely laparoscopic operation. The aim of this study was to investigate on clinical outcomes after laparoscopic hemihepatectomies using PF/ML incisions in comparison with open. Methods:The institutional clinical database of the Hepatobiliary Division at San Raffaele Hospital (Milan, Italy) was retrospectively reviewed identifying cases of laparoscopic and open hemihepatectomies. Three analyses were performed: whole laparoscopic versus open; ML versus open; PF versus ML. Clinical outcomes such as intraoperative blood loss, operative time, postoperative morbidity, motility resumption, perceived pain, and length of stay (LOS) were used for comparisons. Results:Laparoscopy was confirmed to be superior to open approach also in the present series in terms of lower blood loss (300 versus 400 mL,P = .041), fewer complications (14.2% versus 25.9%,P = .024), shorter hospitalization (5 versus 7 days,P = .033), and enhanced recovery in terms of better pain control (P = .035) and mobility resumption (P = .047). Similar outcomes were observed comparing ML alone with open (estimated blood loss 300 mL versus 400 mL,P = .039; complications 13.1% versus 25.9%,P = .037; LOS 5 days versus 7 days,P = .04; lower pain perception,P = .048 and faster mobility resumption,P = .046). No significant differences were observed in postoperative outcomes of PF versus ML. Conclusions:Suprapubic and ML incisions at the end of a pure laparoscopic case lead to comparable outcomes between each other. The adoption of ML incision for specimen retrieval does not affect outcomes of minimal invasiveness.