Hepatic Artery Infusion (HAI) Pump Placement For Unresectable Intrahepatic Cholangiocarcinoma with Vessel Abutment and Intrahepatic Metastasis

The management of unresectable intrahepatic cholangiocarcinoma (ICC) faces major difficulties due to limited therapeutic options for liver-confined disease. This educational video shows technical procedures for robotic hepatic artery infusion (HAI) pump implantation in patients with unresectable ICC. A 72-year-old woman with a centrally-located ICC that involved both portal vein branches received robotic HAI pump placement. The procedure started with diagnostic laparoscopy before moving to robotic arterial dissection for catheter placement in the gastroduodenal artery (GDA) and ending with comprehensive perfusion testing using indocyanine green and methylene blue. Preoperative imaging results showed less disease presence than the intraoperative ultrasound results that displayed multiple hepatic metastases, which led to a change in treatment approach from neoadjuvant to definitive palliative care. The surgeons confirmed proper hepatic perfusion and no abnormal extrahepatic blood flow after they placed the catheter successfully. The robotic HAI pump placement system provides a minimally invasive solution for delivering regional chemotherapy in cases of unresectable ICC through improved visualization and precision compared to open surgical approaches.

The incidence of intrahepatic cholangiocarcinoma (ICC) occurs in 10–20% of primary liver cancers throughout the world.^1–3 The majority of ICC cases are diagnosed at advanced stages, rendering them unresectable due to extensive intrahepatic involvement, vascular invasion, or bilobar distribution.^4,5

Hepatic arterial infusion (HAI) chemotherapy has emerged as a promising treatment modality for patients with unresectable ICC confined to the liver.^6,7 The procedure exploits the preferential arterial blood supply of hepatic tumors, allowing delivery of high-concentration chemotherapy directly to malignant tissue while minimizing systemic toxicity. HAI therapy demonstrates superior response rates compared to systemic chemotherapy alone.^6–8

The current case involves a 72-year-old patient presenting with right upper quadrant pain and imaging demonstrating centrally-located ICC with bilateral portal vein involvement precluding surgical resection. Additional intrahepatic lesions were identified on magnetic resonance imaging (MRI), with elevated CA 19-9 tumor marker (> 200 U/mL) and no evidence of extrahepatic disease on staging studies. The patient had previously undergone a cholecystectomy prior to this procedure.

HAI pump placement via robotic approach offers potential advantages, including enhanced visualization, improved dexterity in confined spaces, reduced postoperative pain, and shorter recovery times compared to open surgical techniques.⁹ The procedure involves placement of a catheter into the gastroduodenal artery (GDA) connected to a subcutaneous pump reservoir, enabling continuous or intermittent regional chemotherapy delivery.

Diagnostic laparoscopy was initiated with optical trocar placement. Following the establishment of pneumoperitoneum at 15 mmHg, systematic evaluation revealed no peritoneal carcinomatosis. Additional ports were placed under direct visualization for robotic assistance.

The robotic system was docked with the patient in a 15-degree reverse Trendelenburg position. Robotic arms were configured with fenestrated bipolar electrocautery, grasper, and retractor for optimal hepatocystic triangle visualization.

Liver ultrasound revealed a centrally-located, segment IV cholangiocarcinoma with bilateral portal vein involvement, confirming unresectability. Multiple hepatic metastases were identified in segments V, II, and III, demonstrating extensive intrahepatic disease and altering therapeutic intent to palliative treatment.

Liver retraction was achieved using 2-0 suspension sutures, utilizing the falciform and round ligaments as natural retraction points while maintaining adequate hepatic blood flow. The hepatoduodenal and gastrohepatic ligaments were divided while preserving the hepatic vagal branch. Previous cholecystectomy adhesions were lysed for improved visualization.

Station 8a lymph node dissection exposed the common hepatic artery (CHA), proper hepatic artery (PHA) and GDA origin. Limited lymphadenectomy was performed, given the extensive intrahepatic disease findings.

Systematic dissection of the CHA, PHA, and GDA was performed. Multiple duodenal branches were ligated to prevent aberrant perfusion. The right gastric artery was divided. Clamp testing confirmed adequate collateral circulation and ruled out median arcuate ligament syndrome.

A subcutaneous pocket was created in the right lower quadrant over the rectus muscle, positioned four fingerbreadths below the costal margin for optimal palpation and access.

The HAI catheter was inserted into the GDA following controlled arteriotomy. Catheter positioning at the CHA-GDA-PHA junction was secured with 2-0 silk sutures so that the catheter does not impinge on to the arterial junction to cause turbulent blood flow and increase the risk of hepatic artery thrombosis. The catheter was tunneled to the subcutaneous pump reservoir.

ICG fluorescence imaging demonstrated uniform hepatic perfusion without extrahepatic flow. Methylene blue injection confirmed appropriate liver perfusion with no aberrant duodenal or gastric staining. Heparin flush maintained catheter patency.

Complete hemostasis was achieved with electrocautery and fibrin sealant application. Bilateral transverse abdominis plane (TAP) blocks provided postoperative analgesia. The robotic system was undocked and port sites inspected.

The HAI pump was attached to the anterior rectus sheath using 4-0 Prolene stitches, positioning it in the under-the-skin pocket. The surgical site was closed in layers: 2-0 Vicryl sutures were used for the subcutaneous layer, and 4-0 Monocryl sutures for deep dermal closure. Any trocar entry points that were 12 mm or larger in diameter also required closure of the fascial layer. The skin was closed using a liquid bandage product for wound cleaning and sealing.

Discussion

The placement of HAI pumps serves as an important therapeutic method for patients who have unresectable ICC that stays within the liver. The robotic method provides better visualization and precise complex arterial dissection while offering better postoperative outcomes and shorter recovery times than traditional open surgical methods. The procedure needs thorough arterial dissection along with exact catheter placement and complete perfusion testing to achieve success. The procedure shows low morbidity rates when performed by experienced teams who select patients correctly.

HAI chemotherapy primarily uses fluoropyrimidines (5-FU, floxuridine) and platinum agents (cisplatin, oxaliplatin) because first-pass hepatic extraction yields high intrahepatic levels with less systemic toxicity. These drugs form the backbone of most regimens: cisplatin alone offers modest benefit, but adding 5-FU (low-dose FP) improves outcomes, particularly with portal vein tumor thrombosis. Intensified variants—high-dose FP or lipiodol-suspended FP (“New FP”)—further enhance delivery, achieve high response rates, and can enable conversion to curative therapy. More recently, oxaliplatin-based FOLFOX combined with sorafenib has shown the strongest randomized survival benefit. Although other agents (doxorubicin, epirubicin, mitomycin) have been used, the evidence consistently favors fluoropyrimidine–platinum combinations as the most effective and best-tolerated choices in advanced disease.¹⁰

The long-term success of this treatment depends on selecting patients correctly and placing catheters precisely while receiving coordinated care from medical oncology and interventional radiology teams for pump maintenance.

Contraindications to HAI pump placement center on hepatic reserve and vascular feasibility. Primary contraindications include poor liver function (from underlying disease, prolonged systemic chemotherapy, or extensive tumor replacement), portal hypertension, portal vein thrombosis, and hepatic artery occlusion—all of which preclude safe placement. A tumor burden exceeding ~70% of liver volume is a relative contraindication. Extrahepatic disease beyond the primary site is also generally a relative contraindication, though highly selected cases may still be considered. Prior external beam radiation or radioembolization is not an absolute barrier, but safety data are limited and warrant caution. Candidates must tolerate general anesthesia and laparotomy (percutaneous placement is limited to select centers). Aberrant or replaced arterial anatomy is not a formal contraindication but can markedly increase operative complexity and risk, reinforcing the need for careful preoperative vascular mapping and multidisciplinary support.^11,12

Aberrant hepatic arterial anatomy occurs in up to 38% of pump placements and, while not usually a contraindication, requires careful planning. The standard approach is to place the catheter in the GDA and ligate accessory or replaced vessels, as cross perfusion typically ensures complete hepatic perfusion. Common anomalies such as GDA trifurcation, aberrant origins, or accessory/replaced hepatic arteries are managed with GDA placement and selective ligation, guided by intraoperative testing. If the GDA is unavailable, alternatives include using the native right or left hepatic artery or creating conduits with grafts or side branches, though these increase the risk of complications and pump failure.¹²

This detailed video can serve as an essential educational resource for hepatobiliary surgeons, surgical oncologists, and robotic specialists who treat unresectable liver malignancies. This procedure provides patients with a life-extending therapeutic choice when resection is impossible.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Nothing to disclose.