Subhashini Ayloo, MD, MPH, Jacob Schwartzman, MD. Rutgers, New Jersey Medical School
Objective: To demonstrate the safety and feasibility of minimally invasive robot-assisted repair of an indeterminate hepatic duct stricture.
Materials and Methods: A 57 year old woman presents with abdominal pain, obstructive jaundice, and elevated LFTs. Diagnostic imaging showed cholelithiasis, choledocholithiasis and a CHD stricture. The stricture remained indeterminate despite evaluation with imaging, endoscopic evaluation. CA 19-9 was moderately elevated. She was offered extrahepatic bile duct resection along with a possible liver resection, depending on intraoperative findings and pathology results.
This video showcases the fine technical details of a minimally invasive robotic approach to bile duct stricture. Diagnostic laparoscopy showed no other pathology. The operation commenced with a cholecystectomy which showed the gallbladder to be chronically inflamed, thickened and with tissue planes obliterated. After identifying the critical structures, the common bile duct was isolated. In the process it became apparent that there was a fistula between the gallbladder and the CHD with a stone in the process of migrating into the duct. The diseased duct was transected and a Roux-en-Y hepaticojejunostomy was performed.
Conclusions: Minimally invasive repair of biliary strictures due to fistulas is safe and feasible, even when encountered unexpectedly in the operating room. The Da Vinci system provides a stable platform with 3-D visualization and improved ergonomics, which facilitate dissection of the bile duct and allow creation of a durable, hand-sewn, single layer end to side hepaticojejunostomy.
Educational/Technical Points: The camera is positioned in the right mid-abdomen. The surgeon’s left arm is positioned in the right lateral abdomen and the right arm is positioned peri-umbilically. The robotic 4th arm is positioned in the left mid-abdomen. A first assistant port is placed inferomedial to the surgeon's left arm. The 4th arm is useful in providing cranial retraction of the liver or the fundus of the gallbladder. Subsequently, it can be used to hold the roux limb stably in position for creation of the hepaticojejunostomy.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92377
Program Number: V037
Presentation Session: Exhibit Hall Theater Video Session I
Presentation Type: EHVideo