Supplementary materials can be found via https://doi.org/10.7602/jmis.2023.26.3.151.

With the advent of robotic surgery, more complex surgeries are being performed via a minimally invasive approach. Despite gaining experience, there is still an absolute risk (0.6%) of biliary injury during laparoscopic cholecystectomy [1]. Bismuth and Majno [2] and Strasberg and Brunt [3] described the classification for bile duct injuries and extensive literature is available for its management. Currently, open Roux-en-Y hepaticojejunostomy (RYHJ) is the most preferred method. A minimally invasive technique, especially the laparoscopic approach, is used by surgeons primarily for type 1 and 2 strictures but has yet to gain popularity due to the technical challenges encountered, mainly during reconstruction. There are minimal data on the robotic approach for the repair of post-cholecystectomy biliary strictures [4,5].

This video article describes our technique of total robotic RYHJ for a patient with post-open cholecystectomy Bismuth type 2 biliary stricture.

The patient is a 43-year-old female who was referred to our centre with complaints of pain in the right upper abdomen and jaundice following laparoscopic cholecystectomy converted to open cholecystectomy elsewhere; common bile duct injury was detected intraoperatively and the procedure was converted to open cholecystectomy and primarily repaired over an internal stent. The patient had a bile leak postoperatively that healed over a period of 2 weeks. Endoscopic retrograde cholangiography was attempted but she was found to have a complete common bile duct cut-off. The patient developed a stricture over a period of 2 months and on evaluation with magnetic resonance cholangiopancreatography she was found to have a type 2 Bismuth biliary stricture. We planned and performed a total robotic RYHJ using indocyanine green (ICG) dye.

The patient was placed in a reverse Trendelenburg position and a pneumoperitoneum was created with the help of a Veress needle to a pressure of 10 to 12 mmHg. The ports were placed in the following positions: R1, right anterior axillary line just below the subcostal margin; R2, right mid-clavicular line at the level of the umbilicus; R3, camera port placed ~2 cm below the umbilicus; and R4, left anterior axillary line ~2 cm below the subcostal margin. A 12-mm assistant port was placed between the camera port and the left-sided robotic working port ~2 cm below the umbilicus (Supplementary Video 1). The da Vinci Xi surgical system (Intuitive Surgical) was utilized and the robot was brought into the surgical field from the patient’s right and docked.

The instruments were placed as follows: fenestrated bipolar forceps in arm R1, Maryland bipolar forceps in R2 and scissors with monopolar electrocautery in R4; 10 mg of ICG (Aurogreen) dye was given at the start of the procedure so that it is excreted in the ductal system after 30 to 45 minutes.

Dense adhesions were encountered between in the perihepatic, subhepatic region and liver to the duodenum and the stomach. Adhesiolysis was done in the subhepatic region with blunt and sharp dissections similar to the open approach. Once adequate adhesiolysis was done and the hilum exposed, the common hepatic duct was identified by switching between the normal and firefly modes of the da Vinci Xi system and was dissected up to the strictured part. Fenestrated bipolar forceps in the fourth arm were used to retract the liver with the help of a gauze piece. Next, the hilar plate was lowered using Maryland forceps and blunt dissection. Once the left duct was exposed for a length of about 2.5 to 3 cm, choledochotomy was done over the common hepatic duct (proximal to the stricture), which was extended over the left hepatic duct to get an adequate stoma size of around 2.5 cm. A gush of fluorescent green bile under firefly mode confirms choledochotomy and differentiates it from vascular structures. Now the attention is diverted to the infracolic compartment to create the Roux limb.

The transverse colon was lifted up and the ligament of Treitz was identified; the jejunum was marked 25 cm distally for division. Endo-GIA 45-mm blue staple load (Medtronics), inserted via the 12-mm assistant port, was used to divide the jejunum after scoring the small bowel mesentery. A defect was created with scissors to the right of the middle colic artery in the mesentery of the transverse colon or in a plane just above the third part of the duodenum in case of bulky mesentery, and the biliary limb of the jejunum was brought up through this defect to the hilum to provide a retro colic position. Enterotomy is made with the help of scissors on the antimesenteric border to match the size of the ductotomy. A 4-0 polyglactin barbed (V-loc, Covidien) suture was used to perform a side-to-side hepaticojejunostomy. The posterior layer (lower) is started from the right side (common hepatic duct) and brought to the opposite corner (edge of the left hepatic duct) in a continuous fashion. Another similar suture was used for the anterior layer, which also began from the right side and was brought out from the left side. The last few throws were tightened in the end to ensure adequate space for completing the anastomosis. Finally, both sutures were tied together to form a secure knot. The bile leak was checked with white gauze and also confirmed using the ICG-firefly mode. The gauze was left in place and the camera again shifted to the infracolic position to perform a side-to-side functional end-to-end jejunojejunostomy. Enterotomies were made on the antimesenteric border of both limbs with electrocautery scissors and the anastomosis was performed using one Endo-GIA 45-mm blue load. The common enterotomy site was closed in two layers: inner 3-0 polyglactin 910 (V-loc) and outer 3-0 polydioxanone (PDS) sutures. The mesentery was closed with interrupted PDS sutures. Finally, a drain was placed from the R1 port site in the right lower quadrant into the subhepatic space.

The total operative time was 420 minutes (docking plus console) and the estimated blood loss was 100 mL. The patient was shifted to a normal ward in the postoperative period. She was allowed liquid orally on postoperative day (POD) 1 and was gradually escalated to a soft diet by POD 4. Her drain was removed on POD 4, and she was discharged on POD 4 with an improving liver function test. After a follow-up of 6 months she is doing well, with a normal liver function test and no intrahepatic biliary dilatation on the abdominal ultrasound scan.

The spectrum of robotic surgeries is constantly expanding in the field of biliary surgery due to the multifactorial advantages of the robotic system, such as magnification, depth perception, tremor filtration, enhanced dexterity, stable surgical field and wristed articulation, which led to it becoming an excellent surgical tool in complex biliary reconstruction. Although robotic hepaticojejunostomies are being performed increasingly in cases such as choledochal cysts or as part of surgical procedures such as pancreaticoduodenectomy, its use for biliary reconstruction in post-cholecystectomy biliary strictures still needs to be more widespread [5–7]. There are several reasons preventing this usage, including previous open surgery in an attempt to repair acute bile duct injury, dense adhesions and difficult access to the hilum and left duct. Through this video article, we describe our technique of total robotic RYHJ for a case of post-open cholecystectomy Bismuth type 2 biliary stricture.

Getting the perfect port placement is of the utmost importance in any minimally invasive surgery. We found the positions described above to be convenient, with minimal or no inter-arm collision, and later used efficiently in the infracolic compartment for jejuno-jejunostomy and routinely used in right upper quadrant surgery at our centre [6]. The assistant port is useful for introducing gauze, sutures with needle, suctioning and an Endo-GIA stapler, thus avoiding a 12-mm robotic port.

The fourth arm retracts the liver under a gauze piece and can be manipulated as the surgery proceeds. The key steps that differentiate it from open surgery are, firstly, the avoidance of perihepatic adhesiolysis, thus providing the liver with natural traction. Secondly, the identification of the bile duct entirely depends on ICG dye, so it must be injected at least 30 to 45 minutes previously. ICG dye also helps to detect any anastomotic leak at the end of the procedure. Lastly, the anastomosis starts from the right side, as opposed to open surgery where the surgeon stands on the right side of the patient and preferably starts the anastomosis from the left side.

Technical aspects for good long-term outcomes include well-vascularized ducts, no tension, biliary epithelium mucosa-to-mucosa anastomosis with the largest possible diameter and adequate drainage of all hepatic segments [8,9]. These principles should also be followed in robotic surgery and the aim should be to ensure excellent long-term patency in these patients with benign aetiology. Hence, patient selection is the key, and type 1 and 2 Bismuth strictures should be selected in the initial learning curve.

In conclusion, robotic RYHJ for post-open cholecystectomy Bismuth type 2 biliary stricture can be safely performed using a robotic approach following all the principles of open surgery for good long-term results.

Ethical statements

Since this is a video article that reviewed electronic charts and computed tomography readings, and personal information protection measures are well established, the need for formal consent from the patients was waived by the institutional ethics committee (No. AIIMS/IEC/2022/5415).

Authors’ contributions

Conceptualization, Project administration: PV

Data curation, Visualization: PV, KSR

Formal analysis: PV, SCS, KSR

Investigation: All authors

Methodology: PV, VKV, SB, LA

Writing–original draft: PV, KSR

Writing–review & editing: SCS, VKV, SB, CLB

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available on request from the corresponding author.