Delayed Repair of E2 Bile Duct Injury With Robotic Roux-en-Y Hepaticojejunostomy

Bile duct injury is a rare complication in the modern era of minimally invasive laparoscopic and robotic surgery; however, it can lead to serious short- and long-term consequences.^1,2 Repair of bile duct injury with Roux-en-Y hepaticojejunostomy is a technically demanding operation especially when undertaken laparoscopically. ³ Newer robotic technology improves surgeon’s dexterity for fine suturing tasks such as in creating a delicate hepaticojejunostomy, which overcomes the limitation of conventional laparoscopic approach. As surgeons accumulate more experience in minimally invasive bile duct surgery for benign and malignant tumors in the United States, the accepted surgical approaches gradually move from open to robotic technique. ⁴ Technical description of robotic RY hepaticojejunostomy is still very limited in the literature, and many high-volume hepatobiliary centers are still not familiar with its technical details. In this video, we describe our robotic technique for delayed repair of an E2 bile duct injury.

A 53-year-old man presented in our office with a bile duct injury after an urgent laparoscopic cholecystectomy. One week later, the patient was readmitted for fever, leukocytosis, and jaundice to a local hospital, consistent with acute cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) revealed an abrupt cutoff of the mid common bile duct, which led to a failure of biliary cannulation. A percutaneous transhepatic cholangiography (PTC) drain was placed to temporarily decompress the intrahepatic biliary tree. Further preoperative work-up with a contrast imaging CT scan ruled out a presence of concomitant vascular injury. Due to the timing of the biliary duct injury diagnosis being beyond 7 days from the index operation, a delayed repair is recommended to allow for cessation of perihilar inflammation and patient’s clinical recovery.

The delayed repair at 3 months began with a diagnostic laparoscopy and adhesiolysis to find the proximal common hepatic duct. Once the anatomy of the hilar area and the leaking biliary duct were confirmed, a single RY hepaticojejunostomy was subsequently prepared using 60 cm of a roux limb. The jejunojejunostomy was created with a side-to-side stapled technique approximately 40 cm from the ligamentum of Treitz. The roux limb was transposed antecolically toward the hilar plate to create a wide hepaticojejunal anastomosis using a continuous running technique. In order to ensure long-term patency of the anastomosis, the biliary opening was extended cephalad to include the ventral wall of the transverse portion of the left duct (Hepp-Couinaud technique) to construct a wide 2 cm hepaticojejunostomy. 4-0 absorbable barbed sutures were used to fashion the hepaticojejunostomy anastomosis starting from the 9 to 3 o’clock positions. The robotic system greatly facilitated this fine suturing step with high precision. A closed suction surgical drain was placed in the infrahepatic fossa at the end of the operation.

Operative duration was 3 hours with 50 cc of blood loss. Post-operative recovery was uneventful, and patient was discharged on post-operative day #4. The surgical drain was removed before discharge after confirming an absence of biliary anastomotic leak. No complications were seen at a 6-month follow-up.

In conclusion, robotic approach for delayed repair of E2 bile duct injury is safe, feasible, and reproducible with excellent clinical outcomes. This technique can provide an alternative minimally invasive method to the existing traditional open operation.