Ethical approval for this study was obtained from the Institutional Review Board of the Affiliated Tumor Hospital at Xinjiang Medical University (Approval No. S-2024080). Meanwhile, the patient in this study agreed to have her clinical data used for publication, and she was informed of the purpose of the study and signed the informed consent form. Figure 1 illustrated the timeline of clinical visits and the diagnostic history of this patient. A 58-year-old female presented in July 2024 with paroxysmal diarrhea and vomiting persisting for one week. Her surgical history includes appendectomy (1984), acoustic neuroma resection (2004), and intracranial cyst excision (2015). The patient had no documented family history of gastrointestinal cancers or hereditary cancer syndromes. Physical examination revealed stable vital signs and unremarkable assessments of the abdomen, cardiopulmonary system, and lymphatic system. Laboratory studies demonstrated normal hepatic function and tumor markers within reference ranges (Table 1).

Based on the contrast-enhanced computed tomography (CT) findings, the gallbladder wall demonstrated irregular thickening with heterogeneous enhancement during the arterial phase (Fig. 2A), followed by progressive and persistent enhancement in the venous phase (Fig. 2B). Concurrently, focal thickening at the distal CBD was observed in the arterial phase (Fig. 2C), with gradually increasing enhancement intensity in the venous phase (Fig. 2D). Further reconstructions in the coronal plane (Fig. 2E) and sagittal plane (Fig. 2F) revealed distal CBD stenosis and proximal dilatation. These features collectively indicate gallbladder wall thickening with an intraluminal soft-tissue mass, suggesting GBC with concomitant invasion of the CBD. Subsequent magnetic resonance imaging (Fig. 2G–K) and magnetic resonance cholangiopancreatography (Fig. 2L) further corroborated these diagnoses.

After a multidisciplinary discussion, surgery was performed on July 27, 2024. According to the relevant operation guidelines, anesthesia, disinfection, connection of the robotic arm, and establishment of pneumoperitoneum were carried out in sequence. After a systematic abdominal exploration, the results were as follows: The gallbladder was significantly enlarged; the CBD was dilated, and no obvious metastatic lesions were found in the abdominal cavity.

Following adhesiolysis, Calot triangle was meticulously dissected to isolate the cystic structures. The cystic artery was clipped and divided. The cystic duct was triple-clipped and transected 5 mm from the CBD (Fig. 3A). The gallbladder was excised from the hepatic bed, revealing a lumen filled with fish-fleshy nodules highly suspicious for malignancy intraoperatively, prompting frozen section analysis. Rapid pathology consultation reported moderately differentiated adenocarcinoma of the gallbladder, with cystic duct margins negative for carcinoma infiltration. Subsequently, an extended radical cholecystectomy was performed. A Pringle maneuver with intermittent hepatic vascular exclusion (15 minutes clamping and 5 minutes release) was applied. After marking liver segments IVb and V 2 to 3 cm away from the gallbladder bed (Fig. 3B), a wedge-shaped resection of liver tissue and a portal lymphadenectomy from the hepatic hilum to the pancreaticoduodenal region were performed (Fig. 3C). Concurrent intraoperative choledochoscopy was performed (Fig. 3D). Specifically, a choledochoscope was inserted via an anterior wall incision of the CBD for biliary tree exploration. Direct visualization revealed diffuse dilation of the extrahepatic bile ducts and a papillary-like mass at the lower end of the CBD (Fig. 3E). The duodenal papilla exhibited inflammatory edema, with no space-occupying lesions or impacted stones identified.

Subsequently, the gastrocolic ligament was opened (Fig. 3F), and the junction of the pancreatic neck and body was dissected. Along the celiac trunk and its bifurcation (common hepatic artery and splenic artery), lymphadenectomy of groups 7, 8, 9, and 11 was performed. Then the Helne vein was severed. Intraoperative reevaluation of the biliary system was performed. A fiberoptic choledochoscope was inserted through a longitudinal incision in the anterior wall of the CBD. Smooth mucosa and unobstructed orifices were seen in the left and right hepatic ducts and their second-order branches. A grayish-white, friable mass (1.0–1.5 cm in diameter) was found growing circumferentially in the distal CBD near the ampulla of Vater, causing luminal obstruction. Given the primary GBC, metastatic involvement of the distal CBD was suspected.

After multidisciplinary consultation and thorough communication with the family, radical pancreaticoduodenectomy was performed as follows: Following ligation of the right gastric and gastroepiploic vessels, the stomach was transected 5 cm from the pylorus on the lesser curvature with a linear stapler, and the stump was oversewn (Fig. 3G). The common hepatic duct was then ligated with hemostatic clips and transected with scissors (Fig. 3H). The jejunum was divided 10 cm distal to the ligament of Treitz using a linear stapler (Fig. 3I). Its mesentery was dissected and ligated, and the proximal jejunum was passed behind the superior mesenteric artery (SMA) to the right upper quadrant. The pancreatic uncinate process was dissected along the superior mesenteric vein (SMV); its tributaries to the SMA and SMV were ligated and divided, followed by transection of the pancreatic neck (Fig. 3J). An extended retroperitoneal lymphadenectomy was performed from the anterior inferior vena cava to the left border of the aorta. The hepatoduodenal ligament was dissected, the gastroduodenal artery was doubly ligated and divided, and the CBD was transected 1 cm below the confluence and marked. The proximal jejunum was mobilized to the right border of the SMV and brought retrocolically into the subhepatic space. Finally, the uncinate process was resected by sharp dissection along the right aspect of the SMV–portal vein axis, ligating its arterial branches from the SMA, which allowed en bloc removal of the specimen (Fig. 3K).

Digestive tract reconstruction was performed as follows: First, a distal jejunal loop was passed retrocolically to the right upper quadrant, and a properly sized stent was inserted into the pancreatic duct. After confirming the position of the pancreatic duct, a mucosa-to-mucosa pancreatojejunostomy was performed between the pancreatic remnant and the jejunal side wall (Fig. 3L). Second, 10 cm distal to the pancreatojejunostomy, a choledochojejunostomy was performed with continuous suturing between the ductuli hepaticus communis and the jejunal side wall (Fig. 3M). Third, 60 cm distal to the choledochojejunostomy, a gastrojejunostomy was performed using a disposable endoscopic linear stapler on the posterior wall of the stomach (Fig. 3N). All anastomoses and closure sites were reinforced and buried, thereby completing the gastrointestinal reconstruction. Finally, we wrapped the hepatic artery and the stump of the gastroduodenal artery (GDA) in a shell-like manner for hemostasis, protection, and prevention of postoperative bleeding (Fig. 3O).

Following irrigation of the abdominal cavity and meticulous confirmation of hemostasis at the surgical site, with no active bleeding or pancreatic leakage observed, hemostatic agents were applied to the pancreatic remnant and the operative field. One drainage pipe was placed below the pancreas, one above the choledochojejunostomy, and one below it (Fig. 3P). All were exteriorized through abdominal wall puncture sites. After ensuring no items were left inside by checking sponges and instruments, the abdomen was closed in layers, and the surgery was concluded. The operation time for the robotic surgery was 580 minutes. There was a small amount of bleeding during the procedure, but no blood transfusion was required.

The histopathological assessment revealed that the morphology of the gallbladder lesion (Fig. 4A) and the CBD lesion (Fig. 4B) was similar, as indicated by the hematoxylin-eosin staining results. Postoperative pathology confirmed moderately differentiated adenocarcinoma of the gallbladder, staged as pT2aN0M0. Immunohistochemical profiling demonstrated (Fig. 4C): Aggressive molecular phenotype: p53-mutant pattern (diffuse strong nuclear staining in >80% tumor cells); Intact DNA repair machinery: Retained expression of all mismatch repair proteins (MLH1+, MSH2+, MSH6+, PMS2+); High proliferative activity: Ki-67 labeling index of 40% in tumor hotspots; Actionable therapeutic target: HER2 overexpression (3+ with complete intense membranous staining); Viral etiology exclusion: Epstein–Barr virus-encoded RNA in situ hybridization negative. These findings collectively define a p53-mutated/MSS (microsatellite stable)/HER2-positive molecular subtype, warranting consideration for anti-HER2 targeted therapy in adjuvant settings while indicating limited benefit from PD-1/PD-L1 inhibitors. Margin clearance >1 mm and absence of perineural invasion on ductal margins support R0 resection completeness. This patient underwent a one-year follow-up. The CT scan results indicated that no recurrence or metastasis of the tumor was observed during the arterial and venous phases (Fig. 5A and B). No bile duct stenosis or dilation was observed in the coronal and sagittal views (Fig. 5C and D). In conclusion, this case demonstrates the applicability and safety of the Da Vinci Xi system in performing HPD surgeries.