Re: Robotic Surgery of the Liver and Biliary Tract ( J Laparoendosc Adv Surg Tech A 2019;29:141–146 )

Dear Editor,

We read with great interest the article by Guerra et al., ¹ titled “Robotic Surgery of the Liver and Biliary Tract.” The authors stated that the robot can be used to perform various types of liver (and biliary tract) surgeries quite safely and competently.

The authors performed a systematic literature review and they reported that until June 2017 the literature failed to provide substantial data on the treatment of benign biliary conditions. They found only anecdotal data, mostly simple case reports, concerning choledocholithiasis management, resection of choledochal cysts, redo of prior bilioenteric anastomoses, and surgical revision of iatrogenic bile duct injuries.

Since the review of Guerra et al. ¹ is now published in a special edition of JLAST, concerning “Innovations in Robotic Surgery,” we would like to discuss further advances concerning robotic-assisted bile duct repairs that have been published after June 2017.

The first case report regarding the treatment of bile duct injury was published by Prasad et al. ² in 2015. After this case report, Giulianotti et al. ³ published in 2017, their excellent and encouraging results in 14 patients who underwent bile duct repairs by robotic-assisted surgery.

In late 2017, we reported a case series of patients with spontaneous biliary-enteric fistula after iatrogenic bile duct injury. ⁴ In this series, 5 patients underwent robotic-assisted Roux-en-Y hepaticojejunostomy. We observed that complex biliary cases could be safely operated by robotic-assisted surgery. We confirmed the safety and efficacy of the robotic approach in a cohort of 30 patients who underwent robotic-assisted bile duct repair. ⁵ We found no intraoperative complications, median estimated blood loss of 100 mL, median operative time of 245 minutes, no conversions to open or laparoscopic surgery, no mortality, median length of stay of 6 days, and an overall morbidity rate of 23.3%. A recently published case report by Ayloo and Schwartzman, ⁶ described the bile duct repair of a Strasberg class E1 injury. They described the degrees of freedom and stability of the robotic platform during exposure of hepatic hilum, positioning of the Roux limb, and suturing of the common bile duct. And Marino et al. ⁷ reported a prospective cohort of 12 patients. They reported no conversion to open surgery, mean blood loss of 252 mL, mean operative time of 260 minutes, mean length of stay of 9.4 days, 2 patients with morbidity (subhepatic abscess and cholangitis), and one reoperation.

We recently published a retrospective comparative study of patients with iatrogenic bile duct injury who underwent robotic or laparoscopic hepaticojejunostomy. We found comparable rates of operative times (P = .316), estimated blood loss (P = .055), time to resume diet (P = .011), and hospital length of stay (P = .015). The overall morbidity rate was similar between laparoscopic (27.5%) vs. robotic (22.8%) repairs (P = .644). In the laparoscopic group the actuarial primary patency rate was 92.5% during a median follow-up of 49 (43.2–56.8) months, whereas in the robotic group the actuarial primary patency rate was 100%, during a median follow-up of 16 (12–22) months. The overall primary patency rate was 96% (laparoscopic 92.5% vs. robotic 100%, log-rank P = .617). ⁸

As the authors stated, the principal advantages of robotic surgery over conventional laparoscopy are stable and magnified three-dimensional view, increased range of motion, and augmented surgical dexterity, particularly useful when working in confined spaces such as pelvis, but also the hepatic hilum. ¹ Based on our experience we should add the elimination of tremor, increased versatility with ambidextrous handling, and ease of suturing during ducts repair. ⁵

Despite there is no high-quality studies and there is no available data regarding long-term results (>10 years) of robotic-assisted bile duct repairs, we believe that in experienced hands the robotic approach could be safely offered to patients with iatrogenic bile duct injury.