Robotic hepaticojejunostomy for biliary stricture after liver transplantation: technical description and case series

Abstract

Presenter: Jason Hawksworth MD | MedStar Georgetown University Hospital Background: Biliary strictures after liver transplantation are common and when refractive to endoscopic and percutaneous intervention require surgical biliary revision. Traditional open biliary revision may result in substantial wound morbidity and prolonged hospitalization in this high-risk population. Robotic technology facilitates minimally invasive biliary reconstruction and has not previously been described following liver transplantation. Methods: A brief description of the robotic approach is as follows: Peritoneal access is obtained at the umbilicus and a 12mm assist port is placed. Robotic ports are placed across the mid abdomen parallel to the umbilical port including 3x 8mm ports and 1x 12mm port. Lysis of adhesions is performed until the liver hilum is isolated. The bile duct is encircled and the stricture resected until healthy appearing donor bile duct is visualized. The hilar inflow structures are carefully preserved during this dissection. The inframesocolic compartment is exposed and the first jejunal loop divided with the robotic stapler. The roux limb is routed retrocolic and an isoperistaltic end-to-side jejunojejunostomy created with the robotic stapler. The common enterotomy is closed with running suture. Attention is returned to the liver hilum where an end-to-side hepaticojejunostomy is created with interrupted monofilament suture. Ultrasound is used during the case to aid in identification of the hilar structures and at the end of the case to confirm patency of the hepatic artery. The robotic cases were retrospectively compared to historical open cases over a time period from May 2013 to October 2020, including demographics, perioperative complications and outcomes. All patients had at least 3 months follow up. Results: During the study period there were 3 robotic and 4 open surgical biliary revisions. All cases were hepaticojejunostomies for choledochocholedochostomy related anastomotic strictures. In one robotic case involving a donation after cardiac death (DCD) graft, the bile duct was also noted to be sclerotic up to the liver hilum and the anastomosis was fashioned to the right and left hepatic ducts. In all cases the biliary strictures presented >90 days after transplant and were refractive to multiple endoscopic and percutaneous interventions. Median (range) case time was longer the in the robotic (373 minutes (286-373)) compared to open (280 minutes (163-321)) group. Blood loss was minimal ( < 50mL) in all robotic and open cases. The median length of stay was lower in the robotic (4 days (1-4)) compared to open (7 days (4-10)) group. Morbidity included 2 wound infections in the open group (grade 2), 1 gastrointestinal bleed requiring a blood transfusion in the robotic group (grade II), 1 infected hematoma in the robotic group (grade IIIa) and 1 bile leak on the open group (grade IIIa). Nadir bilirubin was similar between the robotic (0.2 (0.2-0.3)) and the open (0.3 (0.2-0.4)) group. Nadir alkaline phosphatase was also similar between the robotic (154 (92-245)) and the open (132 (72-166)) groups. There was no mortality in either group. Conclusion: Robotic biliary revision is a safe alternative to traditional open surgery for refractive biliary strictures after liver transplantation.