Robot-Assisted Repair of E 1 Biliary Ductal Injury with Roux-en-Y Hepaticojejunostomy

Introduction

Iatrogenic common bile duct (CBD) injury remains the most serious complication of laparoscopic cholecystectomy. The incidence of CBD injury has ranged from 0.4% to 0.6%, however, may have decreased in recent years to rates comparable to the “open era.”^1,2 Nevertheless, given the commonality of gallbladder surgery (with more than 750,000 cholecystectomies performed annually in the United States alone), ³ CBD injury will continue to be a significant complication with significant impact on health care costs and patient quality of life. ² Currently, the majority of CBD injuries are repaired with an open operation after a period of several weeks to allow inflammation to subside. Robot-assisted laparoscopic surgery, with its added degrees of freedom and stability of the robotic platform, may offer options for minimally invasive repair and may empower surgeons to address this complication in a more timely manner. However, the major challenges to a robot-assisted repair of CBD injury are limited surgeon experience and lack of establishment of the safety and feasibility of this approach. To date, there are only few case reports and small series currently available.^4–6 This video showcases a successful case of robot-assisted repair of an E₁ CBD injury with Roux-en-Y hepaticojejunostomy in the early postoperative period (Supplementary Video S1, CBDI).

Materials and Methods

A 36-year-old woman presented to an outside hospital with acute cholecystitis and underwent laparoscopic cholecystectomy. Postoperatively, her pain persisted with elevated bilirubin. A hepatobiliary iminodiacetic acid scan showed biliary leakage into the gallbladder fossa, and magnetic resonance cholangiopancreaticography showed a distal CBD cutoff sign, consistent with an E₁ injury. She was transferred to our center for further care on postoperative day 5. A percutaneous transhepatic catheter drain was placed for biliary decompression and control of bile leakage. The patient was taken to the operating room for robot-assisted repair of bile duct injury on postoperative day 7.

Results

The robotic camera port was placed in the right mid-abdominal periumbilical area. The robotic left and right arms were placed in the right lateral abdomen and umbilical area, respectively. The robotic third arm was placed in the left lateral abdomen. Two first assistant ports were placed: one between the camera/left arm port of the surgeon and the other between the right arm port of the surgeon and the third arm. The liver is retracted cranially with the third arm of the robot, and omental adhesions to its undersurface are lysed. Multiple biliary pockets are encountered and suctioned. The proximal CBD was identified, delineated, and trimmed proximal to healthy bleeding edges. The distal CBD was identified and suture-ligated. A Roux limb of jejunum was bypassed and a jejunojejunostomy made using an endo-gastrointestinal anastomosis to create a common channel and a double layer hand-sewn closure of the common enterotomy. The Roux limb was brought up to the right upper quadrant and held in place with the robotic third arm. A choledochojejunostomy was performed antecolic using 4–0 absorbable sutures in running manner for the posterior layer and interrupted manner for the anterior layer. Port sites are closed.

Console time for the procedure was 4 hours with minimal blood loss and no requirement for transfusion. The patient had an uneventful postoperative course with prompt normalization of liver function tests and was discharged home on postoperative day 3.

Discussion

We present a case of early minimally invasive repair of CBD injury after laparoscopic cholecystectomy. Case reports/series are the only available data supporting the use of robot-assisted laparoscopic surgery in the repair of biliary ductal injuries, including one report of robotic repair of biliary-enteric fistula secondary to ductal injury.^4–6 To date, there are no large series or randomized trials comparing robotic hepatobiliary surgery to laparoscopic hepatobiliary surgery with regard to outcomes or cost. In addition, there are no series examining the timing of CBD injury repair. Such trials are not practical at this time given the rarity of CBD injury and the small number of surgeons with the technical expertise required to perform this operation via a minimally invasive approach.

Although CBD injuries are rare, their impact on the health care system can be immense. ² CBD injuries are also the most common cause of litigation after laparoscopic cholecystectomy, partly because of the physical and psychological morbidity associated with these injuries.^7,8 Early, successful minimally invasive repair may decrease morbidity and may therefore minimize the legal consequences of the index operation. Any improvements in technique that can facilitate early repair are thus of paramount importance.

The authors notice several advantages to the robotic approach compared with laparoscopy, consistent with the observations of other authors. First, the three-dimensional visualization provided by the robotic platform allows for superior visualization and exposure of the hepatic hilum and identifying critical structures within the porta hepatis. Second, the stability of the robotic third arm provides consistent retraction and aids in stable positioning of the Roux limb during hepaticojejunostomy, which avoids concurrent movement of the first assistant linear instrument during a fine suturing of the duct. The dynamic retraction of the liver depending on the step or stage of the procedure by the third arm of the robot avoids constant need to communicate with the first assistant or having to take their role to obtain the setup the primary surgeon would have intended to have. Third, the improved ergonomics and increased degrees of freedom afforded allows for suturing at difficult angles, including fine, consistent, and satisfactory take of tissues during suturing with the nondominant hand when necessary. This creates efficiency movement by conserving the number of attempts to obtain a perfect bite of the tissues during suturing or to obtain a way of exposure and maintain it until the task is completed. As a result, the authors believe that in certain difficult cases, a robotic approach may improve the likelihood of successful procedure completion via a minimally invasive approach compared with standard laparoscopic approach. Further study is necessary to confirm or refute this claim, but in general, most surgeons with expertise in robotic systems concur with these observations.

Conclusion

Robot-assisted early repair of CBD injuries is safe and feasible in select patients. This approach should be offered, if feasible, to patients by surgeons with sufficient expertise in hepatobiliary and robotic surgery. Patient selection should be highly selective and the operation should be performed at tertiary care centers, until more overall experience is obtained by the surgical community. Early, minimally invasive repair has great potential to minimize morbidity of the index operation and accelerate patient recovery. In doing so, the terrible consequences following CBD injury, including the risk for litigation, can be mitigated.