Robotic Hepaticojejunostomy for Biliary Stricture (Bismuth Strasberg E3) after Laparoscopic Cholecystectomy

Abstract

Purpose: Iatrogenic injury to the extrahepatic biliary duct most commonly occurs during laparoscopic cholecystectomy. It’s a complex problem and mismanagement can result in lifelong disability and chronic liver disease. Due to the unforgiving nature of the biliary tree surgical repair must be performed with great precision. Robotic surgery has the advantage of 3D visualization and a larger range of motion enhancing accurate reconstruction. Methods: This video describes a robotic extrahepatic biliary duct resection with Roux-en-Y hepaticojejunostomy with re-implantation of the right and left biliary duct. The patient suffered from a stricture near the hilum after laparoscopic cholecystectomy 9 years ago. The biliary stenosis was classified as a Bismuth Strasberg E3 injury. Four robotic 8mm ports were placed and one assistant 12mm port. Hilar dissection showed 8 locking polymer clips near the common hepatic duct and the hilum. After removal of the clips the stenotic common hepatic duct was resected. The right and left hepatic duct were made ready for anastomosis by bringing them together with resorbable sutures on the same plane using the ‘double barrel technique’. A robotic Roux-en-Y hepaticojejunostomy was performed to maintain the continuity of bilio-enteric tract. Results: Operative time was 170 minutes, and blood loss was 30 cc. There were no intraoperative complications. The postoperative course was uneventful, and the patient was ready for discharge on postoperative day 5. Conclusion: Robotic hepaticojejunostomy is a feasible technique for management of complex biliary injury in selected patients.