This video demonstrates Robotic Roux-en-Y Hepaticojejunostomy in a Post-cholecystectomy Bile Duct Injury. Roux-en-Y hepaticojejunostomy anastomosis is the treatment of choice for common hepatic duct injury type E2. It has been performed laparoscopically with the advancement of laparoscopic skills. Recently, a robotic surgical system was introduced, providing laparoscopic instruments with wrist-arm technology and 3-dimensional visualization of the operative field. We present a case of a female patient who had undergone elective cholecystectomy 2 mo ago for gall stones and had a common bile duct injury during surgery. As the stricture was old and complete it could not be tackled endoscopically. We did a robotic adhesiolysis followed by robotic Roux-en-Y hepaticojejunostomy. No intraoperative complications or technical problems were encountered. The postoperative period was uneventful and she was discharged on the 4th postoperative day. At follow-up, she is doing well without evidence of jaundice or cholangitis. This is the first reported case of robotic hepaticojejunostomy following common bile duct injury.

Post-cholecystectomy bile duct injury (BDI) is one of the most serious complications of gallbladder surgery, often leading to jaundice, cholangitis, biliary stricture, and long-term morbidity. Injuries occurring during or after cholecystectomy account for the majority of iatrogenic bile duct injuries, frequently related to inflammation, distorted anatomy, or visual misperception during surgery.

For major bile duct injuries, Roux-en-Y hepaticojejunostomy (HJ) remains the gold-standard reconstructive procedure, offering durable biliary drainage and excellent long-term outcomes when performed in specialized centers.

At advanced minimally invasive centers such as World Laparoscopy Hospital, robotic technology is increasingly used to enhance precision in complex biliary reconstruction.

Role of Robotic Surgery in Biliary Reconstruction
Robotic systems provide three-dimensional magnified vision, tremor filtration, and wristed instrumentation, making them particularly valuable for delicate hilar dissection and fine suturing. These features help achieve essential surgical principles such as well-vascularized ducts, tension-free anastomosis, and complete drainage of hepatic segments.
Studies of robotic Roux-en-Y hepaticojejunostomy have shown low blood loss, minimal morbidity, and reduced hospital stay, demonstrating the feasibility and safety of this minimally invasive approach.

Indications for Robotic Roux-en-Y Hepaticojejunostomy
Common indications include:

• Major bile duct transection or stricture after cholecystectomy

• Failed endoscopic or percutaneous management

• Complex hilar strictures (e.g., Strasberg E2–E4 injuries)

• Recurrent cholangitis or biliary obstruction

HJ reconstruction is considered the definitive treatment in most major BDIs requiring surgical repair.

Preoperative Evaluation
Preoperative planning is crucial and typically includes:

• MRCP or CT imaging to delineate biliary anatomy

• ERCP or PTC for drainage and cholangiographic mapping

• Optimization of sepsis, nutrition, and liver function

Early referral to specialized hepatobiliary centers improves outcomes and reduces complications.

Surgical Technique (Robotic Approach)
The procedure generally involves the following steps:

1. Patient Position and Port Placement
   Patient is placed in reverse Trendelenburg with right side elevation to expose the hepatic hilum.

2. Adhesiolysis and Hilar Exposure
   Laparoscopic or robotic adhesiolysis is performed to expose the porta hepatis and biliary confluence.

3. Roux Limb Preparation
   Jejunum is divided approximately 40 cm from the duodenojejunal flexure, and a Roux limb is constructed.

4. Hepatic Duct Preparation
   Scarred bile duct tissue is excised, and healthy duct mucosa is exposed.

5. Robotic Hepaticojejunostomy Anastomosis
   A tension-free mucosa-to-mucosa end-to-side anastomosis is performed using fine absorbable sutures.

6. Drain Placement and Closure
   Subhepatic drain placement ensures early detection of bile leak.

Clinical Outcomes and Prognosis
Long-term studies demonstrate excellent outcomes after Roux-en-Y HJ for BDI, with stricture-free survival approaching 95% at 10 years in some series.
Robotic series have shown:

• Minimal blood loss (often ~100 mL)

• Low complication rates

• Short hospital stay (about 4–6 days)

These results suggest robotic reconstruction can match or potentially improve outcomes compared with traditional open surgery in selected patients.

Advantages of Robotic Reconstruction

• Superior visualization of biliary anatomy

• Precise intracorporeal suturing

• Reduced postoperative pain and faster recovery

• Lower blood loss

• Shorter hospital stay

Robotic EndoWrist technology and stable camera platform significantly improve dissection and suturing around delicate hilar structures.

Challenges and Limitations

• High cost of robotic platforms

• Steep learning curve

• Requirement for advanced hepatobiliary and robotic expertise

Therefore, such procedures should be performed in high-volume centers with multidisciplinary support.

Conclusion
Robotic Roux-en-Y hepaticojejunostomy represents a major advancement in the management of post-cholecystectomy bile duct injury. With enhanced visualization and precision, robotic surgery enables meticulous biliary reconstruction while preserving the benefits of minimally invasive surgery. In specialized institutions like World Laparoscopy Hospital, this approach provides excellent functional and long-term outcomes, making it an evolving standard for complex biliary injury repair.

For more detail log on to: https://www.laparoscopyhospital.com