Subhashini Ayloo, MD, MPH, FACS, Chetan Merchant, MD, Gregory Grimberg, MD, Jacob Schwartzman, MD. Rutgers New Jersey Medical School
Objective: To demonstrate the safety and feasibility of minimally invasive robot-assisted early repair of E1 bile duct transection post laparoscopic cholecystectomy.
Materials & Methods: A 36 year old woman with previous laparoscopic cholecystectomy eight days prior was transferred to tertiary care facility for further management due to elevated liver function test and a positive HIDA scan. MRI/MRCP is consistent with disruption of main bile duct.
This video showcases the technical details of a minimal invasive approach to early repair of completely transected E1 bile duct with a Roux-en-Y hepaticojejunostomy. Diagnostic laparoscopy shows free bile in the abdomen with inflammation in the right upper quadrant (RUQ). Adhesions between the inferior surface of the liver and omentum are lysed. Pockets of bile in the gallbladder fossa are suctioned. The RUQ anatomy is delineated by identifying the proximal and distal bile duct. The edges of the proximal bile duct are debrided. A 40cm Roux-limb is brought out ante-colic to perform an end-to-side hepatico-jejunostomy. An intracorporeal jejuno-jenostomy is created side-to-side using an endo-GIA, with closure of the common enterotomy in double layer hand-sewn fashion. Single layer hepatio-jejujejunostomy is created end to side using absorbable sutures.
Conclusions: Robot-assisted early repair of bile duct transection is safe, feasible and minimizes the impact of the index operation with early definitive management. Minimally invasive approach helps in decreasing the overall morbidity and accelerates patient recovery. The Da Vinci system provides a stable platform with 3-D visualization and improved ergonomics, which facilitate suturing of the anastomoses despite difficult angles.
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. Two first-assist ports are placed, one inferomedial to the left arm and one inferomedial to the 4th arm. The 4th arm is useful in stabilizing the Roux limb in the right upper quadrant, providing a stable platform for suturing the hepaticojejunostomy.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86141
Program Number: V168
Presentation Session: Biliary Videos Session
Presentation Type: Video