Robotic Hepaticojejunostomy for Late Anastomotic Biliary Stricture After Liver Transplantation

Abstract

Biliary strictures after liver transplantation are common and when refractive to endoscopic and percutaneous intervention require surgical revision. Robotic technology facilitates minimally invasive biliary reconstruction and has not previously been described after liver transplantation. Robotic biliary revisions were retrospectively compared to all the historical open cases over a time period from May 2013 to October 2020. During the study period there were 3 robotic and 4 open surgical biliary revisions with a follow-up of at least 6months. All cases were hepaticojejunostomies for late choledochocholedochostomy anastomotic strictures presenting > 4 weeks after transplant and refractive to at least 3 endoscopic and/or percutaneous interventions. Median(range) case time was longer in the robotic group, 373 minutes (286-373) compared to open group, 280 minutes (163-321). The median length of stay was shorter in the robotic group, 4 days (1--4) compared to open group 7 days (4-10). Morbidity included 2 wound infections in the open group (grade II), 1 infected hematoma in the robotic group (grade Ilia), and 1 bile leak on the open group (grade Ilia). There was no biliary stricture recurrence or mortality in either group. Robotic biliary revision is a safe alternative to traditional open biliary revision for refractive biliary strictures after liver transplantation.

Robotic Transplant Surgery Broadening the Playing Field

“…The accompanying video details a step-wise approach including port placement, dissection, and anastomotic technique and demonstrates adjunct techniques of indocyanine green cholangiography and intraoperative ultrasound to facilitate a safe operation. 3 While the low numbers in this case series do not allow for a meaningful comparison between open and robotic approaches, this report does suggest that robotic bile duct revision is a safe option in a small group of patients with refractory strictures. 3 it also adds to a growing body of literature that highlights the subtle but undeniable change in the traditional ''maximally invasive'' mindset of transplant surgery towards one that is increasingly receptive of minimally invasive options for a growing list of indications.…”

“…3 While the low numbers in this case series do not allow for a meaningful comparison between open and robotic approaches, this report does suggest that robotic bile duct revision is a safe option in a small group of patients with refractory strictures. 3 it also adds to a growing body of literature that highlights the subtle but undeniable change in the traditional ''maximally invasive'' mindset of transplant surgery towards one that is increasingly receptive of minimally invasive options for a growing list of indications. [3][4][5] Robotic platforms in particular have found favor with transplant surgeons in the last decade who find improved visualization, fluidity of movement, and wrist articulation of instruments more suited to the technical challenges of transplant and HPB surgery compared to conventional laparoscopic modalities.…”

“…Anas-tomotic biliary strictures, on the other hand, typically present later (> 1 month after LT) and can be challenging to treat with serial endoscopic or percutaneous dilation/stenting being the main stay of treatment and surgery reserved forrefractory cases 2 . Traditionally, surgery has involved abdominal exploration through the LT incision and reconstruction to healthy proximal duct usually via Roux-en-Y hepaticojejunostomy 1–3 . While open surgical revision has a high rate of success, it can be associated with considerable morbidity related to the large incision, postoperative pain, several day hospital stay, and a slow recovery that can last several months 1,3 …”

“…Traditionally, surgery has involved abdominal exploration through the LT incision and reconstruction to healthy proximal duct usually via Roux-en-Y hepaticojejunostomy 1–3 . While open surgical revision has a high rate of success, it can be associated with considerable morbidity related to the large incision, postoperative pain, several day hospital stay, and a slow recovery that can last several months 1,3 …”

“…In the current issue, Hawksworth et al 3 describe their experience with robotic management of anastomotic biliary strictures after LT over the last 7-years and provide a detailed video description of the surgical technique. Of the 7 patients with refractory anastomotic biliary strictures during the study period, 3 were managed robotically and 4 through traditional open approach via bi-subcostal incision.…”