Robotic Roux-en-Y Hepaticojejunostomy for Right Hepatic Duct Transection. Application of Minimally Invasive Technique for High Bile Duct Injury

In the world of general surgery, post-cholecystectomy bile duct injury remains a major complication with potential long-term morbidities. Despite completion of the learning curve, incidence of bile duct injury has doubled since the widespread of laparoscopic cholecystectomy for gallbladder diseases. ¹ The complexity and potential association with vascular injury have also increased in the era of laparoscopic cholecystectomy.^2-4 Minor biliary injury such as cystic duct stump leak, minor tear of the common hepatic duct, or small lateral cut to the common bile duct can be easily managed with endoscopic biliary stenting with good outcomes. However, major biliary injury such as complete ductal transection requires a surgical reconstruction, in the form of immediate or delayed Roux-en-Y hepaticojejunostomy. Traditionally, repair of the bile duct injury is performed by open approach.^3,4 A high bile duct injury above the biliary bifurcation is commonly associated with much smaller ductal caliber, leading to a technically more challenging repair. Description of minimally invasive repair of bile duct injury above the biliary bifurcation is nonexistent in the literature. Herein, we describe our surgical technique of robotic Roux-en-Y hepaticojejunostomy for right hepatic duct transection. A technical video is attached to this article (Supplementary Material).

A 32-year-old otherwise healthy woman was referred to our program with an intra-abdominal fluid collection and severe pain 4 days after a laparoscopic cholecystectomy for chronic cholecystitis. She had a percutaneous transhepatic cholangiogram (PTC) catheter placement prior to transfer due to hyperbilirubinemia. A hepatobiliary iminodiacetic acid scan upon arrival in our facility confirmed the diagnosis of bile leak. A contrast injection study through the existing PTC catheter showed no evidence of contrast entering the common bile duct and duodenum. A further Endoscopic Retrograde Cholangiopancreatography (ERCP) cholangiogram revealed absence of contrast opacification in the right hepatic lobe, consistent with the right hepatic duct transection. Metal clips were visible at the origin of the right hepatic duct, immediately beyond the biliary bifurcation. Only the left hepatic lobe biliary arborization was visible during the ERCP.

A robotic Roux-en-Y hepaticojejunostomy to the right hepatic duct was planned using the da Vinci Xi® model (Intuitive Surgical, Sunnyvale, CA, USA). A diagram of port placement was shown in the video. The robotic system was docked over the patient’s right shoulder. The patient was laid supine on the operating room table with 15° of reverse Trendelenburg and 5° of left-sided tilt. The abdomen was entered via an 8 mm cutdown umbilical incision. An 8 mm robotic trocar was inserted to establish 15mmHg of pneumoperitoneum.

The operation began with a gentle dissection of the adherent transverse colon off the gallbladder bed. The biloma cavity was entered and the bile leak was drained laparoscopically. Exposure of the hepatic hilum was facilitated by placement of a laparoscopic liver retractor. Two metal clips were found on the right aspect of the biliary bifurcation (entrance/junction of the right hepatic duct into the bifurcation), as well as the actively leaking right hepatic duct proximally.

An intraoperative cholangiogram was performed through the leaking right hepatic duct confirming the right hepatic lobe biliary arborization. Roux-en-Y hepaticojejunostomy was then constructed by first elevating the transverse colon cephalad in order to expose the ligamentum of Treitz. Approximately 30 cm distal to the ligament of Treitz, the proximal jejunum was transected using a robotic blue load stapler. The jejunal mesentery was divided carefully using applications of robotic vessel sealer. After measuring approximately 60 cm length for the Roux limb, a side-to-side stapled jejunojejunostomy anastomosis was created. The common enterotomy was manually closed with running 3-0 barbed sutures to complete a watertight anastomosis.

The Roux limb was then transposed to the hepatic hilum in preparation for an end-to-side hepaticojejunostomy. A transmural opening in the jejunum was created. The hepaticojejunostomy was started by placing an index 3-0 barbed suture at the 9 o’clock position (lateral corner). The posterior wall of the anastomosis was constructed first using a running technique toward the 3 o’clock position (medial corner). Each of the needle placements was done meticulously under direct visualization to minimize the chance of postoperative anastomotic leak. The bedside assistant surgeon is working with a laparoscopic suction device to maintain adequate visualization by keeping the operative field clean. Another suture was placed at the 9 o’clock position to create the anterior wall of the anastomosis toward the 3 o’clock position. Adequate visualization is important to avoid inclusion of the posterior wall of the anastomosis during placement of anterior wall suture. Finally, the anterior and posterior sutures were tied together at 3 o’clock position, completing a watertight end-to-side bilioenteric (right hepatic duct to jejunum) anastomosis. Two anchoring stitches were placed between the hilar plate and the seromuscular layer of the jejunum in order to reduce mechanical tension. A closed suction drain was placed in the vicinity.

No evidence of bile leak was observed at the end of the operation. The operative time was 270 minutes without intraoperative complications. Estimated blood loss was 50 mL. Postoperative recovery was uneventful and the patient was discharged home on postoperative day 5. The closed suction drain was removed at her 1 week office follow-up. At her 3-year postoperative surveillance visit, she is doing very well with no evidence of anastomotic narrowing. Her liver function test is normal.

As robotic surgery matures, we believe that minimally invasive technique in biliary surgery will be adopted by the majority of hepatobiliary surgeons. This video showed a feasible, safe, simple, easy to learn, and reproducible technique of major biliary injury repair. This technique of minimally invasive biliary surgery should be included in the modern surgeon’s armamentarium.

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