Subhashini Ayloo, MD, MPH, Jacob Schwartzman, MD. Rutgers, New Jersey Medical School
Objective: To demonstrate the safety and feasibility of minimally invasive robot-assisted bile duct exploration and subtotal cholecystectomy for Mirizzi syndrome.
Materials and Methods: A 42 year old woman presented with abdominal pain, cholangitis, and elevated LFT’s. Ultrasound confirmed cholelithiasis/choledocholithiasis. Two attempts of ERCP with EHL were unsuccessful in clearing the bile duct stones. Diagnostic imaging reconfirmed the findings of cholelithiasis and choledocholithiasis.
This video showcases the fine technical details of a minimally invasive robotic approach to bile duct exploration. Diagnostic laparoscopy showed no other pathology. The operation was commenced with a cholecystectomy, which showed the gallbladder to be chronically inflamed, thickened, and with tissue planes obliterated. The cystic duct and the neck of the gallbladder were firmly fused to the extrahepatic bile duct. Subtotal cholecystectomy was performed secondary to the extent of fistulization of the gallbladder to the extrahepatic duct, followed by exploration of the bile duct and removal of all the stones. Completion cholangiogram showed contrast filling the duodenum.
Conclusions: Minimally invasive subtotal cholecystectomy and CBD exploration for choledocholithiasis is safe and feasible. This could be an alternate option to address significant fistulization of gallbladder to the hepatic duct and when unsuspectedly encountered in the operating room to traditional Roux-en-Y 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. A vascular Fogarty is very helpful to retrieve stones that are impacted distal to the choledochotomy site in these MIS-HPB cases then the traditional biliary fogarty which is short in length.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92379
Program Number: V269
Presentation Session: Video Loop Day 2
Presentation Type: VideoLoop