Robotic-assisted hepatopancreatoduodenectomy for intraductal papillary neoplasm of the bile duct: future approach for minimally invasive biliary surgery

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare biliary tumor, accounting for 4–15% of biliary malignancies (1). It originates from the intrahepatic or extrahepatic bile duct epithelium and is characterized by intraluminal papillary or villous growth, often accompanied by mucin secretion. IPNB exhibits distinct precancerous features and high malignant potential (2). In the 2010 World Health Organization (WHO) classification of digestive system tumors, IPNB was formally recognized as a distinct entity and explicitly defined as a precursor lesion of invasive cholangiocarcinoma. Surgical radical resection remains the primary treatment for IPNB. The choice of surgical procedure depends on the tumor location, extent, and presence of invasive carcinoma (3). Common approaches include partial hepatectomy, pancreatoduodenectomy (PD), and extrahepatic bile duct resection (4). Due to its multicentric growth pattern and propensity for submucosal infiltration, achieving R0 resection is critical for prognosis. This study presents a case of robotic-assisted hepatopancreatoduodenectomy (RHPD) for the treatment of IPNB involving the intrahepatic bile duct, distal common bile duct, and ampulla of Vater.

A 64-year-old female was admitted with a 2-month history of epigastric distension and pain. Laboratory tests revealed elevated serum CA19-9 (2794.51 U/mL), while carcinoembryonic antigen (CEA) and CA15-3 levels were within normal limits. Magnetic resonance cholangiopancreatography (MRCP) revealed a papillary mass (1.0 cm × 0.7 cm) at the distal common bile duct with associated dilation of the biliary system and pancreatic duct, an intraductal papillary lesion within the left hepatic duct, papillary nodular projections and elongated soft-tissue shadows within the dilated bile ducts, and hepatolithiasis in the left hemiliver (Figure 1A-1D). Endoscopic ultrasound (EUS) revealed a papillary mass (1.6 cm × 1.0 cm) in the distal common bile duct. Preoperative diagnosis: IPNB (lesion in distal common bile duct and left hepatic duct) and hepatolithiasis. Preoperative three-dimensional liver visualization was performed to delineate detailed hepatic anatomy and characterize the morphology and spatial distribution of the lesions, thereby facilitating precise surgical planning (Figure 1E,1F). Following multidisciplinary discussion, RHPD with left hemihepatectomy and PD was performed (Figure 1G,1H and Video 1). The operative time was 624 minutes, with estimated blood loss of 500 mL (no allogeneic transfusion required). On postoperative day 2, exploratory laparotomy was performed for intra-abdominal hemorrhage, after which the patient recovered uneventfully and was discharged on postoperative day 23. Final pathology confirmed IPNB (lesion in distal common bile duct and left hepatic duct) with no evidence of invasive carcinoma (Figure 1I). All resected lymph nodes were negative for malignancy. No recurrence was observed during 42 months of follow-up. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article, accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 Preoperative imaging, operation, and tumor specimen in this patient. (A-D) MRCP revealed intraductal papillary lesion within the left hepatic duct, hepatolithiasis in the left hemiliver, and thread sign is observed in the left hepatic duct. (E) It is a preoperative 3D demonstration for surgical treatment. (F) Reconstructions including: pancreaticojejunostomy, cholangiojejunostomy, gastrojejunostomy, and enteroenterostomy. (G) Opening of the right hepatic bile duct and the S7 bile duct are demonstrated, and marked the right hepatic duct. (H) The resected specimens. The extent of resection included sequential removal of the left hemiliver, common hepatic duct, common bile duct, gallbladder, partial distal stomach, duodenum, partial upper jejunum, pancreas head. (I) Histopathological examination revealed that the tumor tissue lacked an ovarian-like stroma and exhibited a papillary growth pattern, characterized by columnar epithelial cells arranged around delicate fibrovascular cores (HE, 100×). CBD, common bile duct; CHD, common hepatic duct; HE, hematoxylin and eosin; LHD, left hepatic duct; MRCP, magnetic resonance cholangiopancreatography; RHD, right hepatic duct.

IPNB is a biliary tumor characterized by significant heterogeneity. Its anatomical classification (intrahepatic, extrahepatic, or diffuse) and pathological subtypes (Type 1/2 or pancreatobiliary, intestinal, gastric, and oncocytic) are closely associated with treatment strategy and prognosis (5). Due to its extensive involvement, diffuse-type IPNB often requires hepatopancreatoduodenectomy (HPD) to achieve radical resection (6). However, HPD is a highly complex and invasive procedure, with an average perioperative mortality rate of up to 13.2% (7). Therefore, a major clinical challenge lies in reducing surgical trauma while ensuring oncological radicality. With advancements in robotic surgery, RHPD has emerged as a minimally invasive alternative. Compared to open surgery, RHPD offers reduced trauma and enhanced precision, particularly in the following key steps:

• Vascular dissection and reconstruction: the robotic system provides clear exposure of critical vessels (e.g., portal vein, superior mesenteric vein, celiac trunk), minimizing vascular injury and bleeding risks.
• Lymph node dissection: robotic systems enable thorough clearance of peripancreatic and regional lymph nodes, improving oncological outcomes.
• Anastomotic techniques: the flexible robotic arms and high-definition visualization facilitate precise biliary, gastrointestinal, and pancreaticojejunal anastomoses, reducing postoperative complications such as bile leaks, enteric fistulas, and pancreatic fistulas.

In this case, the tumor involved the left intrahepatic bile duct, common hepatic duct, common bile duct, and ampulla of Vater, consistent with diffuse-type IPNB. Achieving R0 resection with conventional surgical procedures would have been challenging. We performed RHPD, which resulted in complete tumor removal. Postoperative pathology confirmed negative margins, and no recurrence was observed during long-term follow-up, supporting the oncological efficacy of RHPD in the management of complex IPNB.

It is noteworthy that the long-term prognosis of IPNB after surgery is relatively favorable compared to that of cholangiocarcinoma. However, the presence of invasive carcinoma, lymph node metastasis, or positive resection margins are recognized as adverse prognostic factors. Therefore, achieving R0 resection remains the central goal of surgical treatment. For extensively invasive IPNB, RHPD offers a feasible and effective minimally invasive approach for radical resection. The robotic system provides distinct advantages in performing meticulous dissection, thorough lymphadenectomy, and precise digestive tract reconstruction, thereby contributing to R0 resection and potentially reducing surgical trauma. Nevertheless, RHPD remains a high-risk procedure and should be performed cautiously by an experienced robotic surgery team within a multidisciplinary framework. As technology continues to advance and more clinical data accumulate, robotic-assisted surgery is expected to play an increasingly important role in the management of complex biliary tumors such as IPNB.

Acknowledgments

None.

Footnote

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Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-741/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article, accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

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