Baongoc Nasri, MD, PhD1, Jordan Wilkerson, MD1, Jamie Schutle, MD1, Marius Calin2, Timothy Glass, MD1. 1St VincentHospital, 2Virtua Hospital
Introduction: Cystic duct leak is an uncommon complication following cholecystectomy. Endoscopy is considered safe and effective therapy. However, ERCP in post gastric bypass can be technical challenges. Robotic assisted cystic duct exploration can be an option for cystic duct leak management even at delayed presentation.
Purpose: this is the first case report of delayed repair of persistent cystic duct leak with robotic assisted cystic duct exploration in patient with history of gastric bypass who failed percutaneous interventions.
Materials and Methods: This is a 72 year old female with remote history of gastric bypass who underwent laparoscopic cholecystectomy for acute gangrenous calculus cholecystitis. CT scan and HIDA scan on POD 5 confirmed bile leak. She underwent percutaneous drainage of biloma on POD6, then percutaneous external biliary stent placement on POD 10. Cholangiogram on POD 10 showed persistent cystic duct leak. She has persistent high drain output. However, she denied trial of trans-gastric ERCP. She was transferred to our hospital for further intervention. She underwent robotic assisted cystic duct exploration 8 weeks after the surgery. After pneumoperitoneum via Veress needle, the first 8 mm port was inserted at left subcostal margin. Three additional 8 mm ports were n at left medial mid abdomen, supra umbilicus and right medial lower abdomen. The robot was docked at reverse Trendelenburg. Bipolar was docked at arm 1, scissor at arm 3, camera at arm 2. After extensive adhesiolysis, ultimately the previous clips were found from the previous cholecystectomy. There was no evidence of bile leak on initial inspection, including the use of Firefly technology. Patient received 7.5 ml Indocyanine green prior to coming into the operative suite. Further dissection was carried cephalad where we were able to identify the right hepatic duct. We then continue dissection distally and ultimately the only areas that were felt to be responsible for the leak were 2 small luminal structures near the old clips. Each of these was clipped with Hem-o-lok clips. A complete intraoperative cholangiogram through the transhepatic drain showed no cystic duct leak, contrast in the duodenum and bilateral intrahepatic duct.
Results: Her JP drain was removed POD 5 on the day of discharge. She was seen in the office and recovered well.
Conclusions: This technique has not been previously described in the literature. Robotic assisted cystic duct ligation is a new approach for persistent cystic duct leak. Robotic flexibility enables complex adhesiolysis even at delayed postoperative presentation.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 91885
Program Number: V164
Presentation Session: Video Loop Day 1
Presentation Type: VideoLoop
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