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 skill. 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. 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.

Bile duct injury is a rare but serious complication following cholecystectomy, with the potential to cause significant morbidity if not promptly recognized and treated. The Roux-en-Y hepaticojejunostomy (RYHJ) remains the gold standard surgical procedure for restoring bile flow in cases of major bile duct injury. With the advent of minimally invasive surgery, robotic-assisted RYHJ has emerged as a precise and effective approach, combining the advantages of laparoscopy with enhanced dexterity, 3D visualization, and ergonomic control for the surgeon.

Indications

Robotic Roux-en-Y hepaticojejunostomy is indicated in patients with:

• Strasberg type E bile duct injuries (major duct transection or excision)

• Persistent biliary leaks not amenable to endoscopic or percutaneous interventions

• Post-cholecystectomy strictures causing recurrent cholangitis or jaundice

Preoperative Evaluation

A thorough preoperative workup is essential and typically includes:

• Imaging: MRCP (Magnetic Resonance Cholangiopancreatography) or ERCP to delineate the site and extent of bile duct injury.

• Liver function tests: To assess cholestasis and hepatocellular damage.

• Infection control: Any cholangitis or bile collection should be managed before definitive surgery.

• Nutritional optimization: Important for better postoperative healing.

Surgical Technique

1. Patient Positioning and Port Placement

• The patient is placed in a supine position with slight reverse Trendelenburg.

• Robotic ports are strategically placed to optimize access to the hepatoduodenal region.

• The assistant port is positioned for suction, retraction, and stapling assistance.

2. Adhesiolysis

• Careful adhesiolysis is performed to free the hepatic hilum from post-cholecystectomy scarring.

• The robotic system allows precise dissection around delicate structures like the portal vein and hepatic artery.

3. Identification of Bile Duct Stump

• The proximal bile duct is identified and dissected.

• Intraoperative cholangiography may be used to confirm anatomy.

• Minimal manipulation is key to preserving blood supply and preventing ischemia.

4. Creation of the Roux-en-Y Limb

• The jejunum is divided approximately 20–30 cm distal to the ligament of Treitz.

• A Roux limb of 40–50 cm is brought up in a retrocolic or antecolic fashion.

• The robotic system facilitates precise suturing for the jejunojejunostomy.

5. Hepaticojejunostomy Anastomosis

• The anastomosis is performed end-to-side with fine absorbable sutures.

• Robotic articulation allows meticulous suturing even in narrow spaces.

• A stent may be placed across the anastomosis to facilitate bile flow and prevent stricture formation.

6. Closure and Drain Placement

• Hemostasis is confirmed, and a drain is placed near the anastomosis.

• Ports are removed under direct vision, and the abdomen is closed.

Postoperative Care

• Early mobilization and respiratory exercises are encouraged.

• Liver function tests and bilirubin levels are monitored.

• Oral intake is gradually resumed once bowel function returns.

• Follow-up imaging may be performed to ensure patency of the anastomosis.

Advantages of Robotic Approach

• Enhanced precision: 3D visualization and wristed instruments allow precise dissection and suturing.

• Reduced blood loss: Robotic control minimizes trauma to vascular structures.

• Faster recovery: Smaller incisions and minimally invasive technique contribute to shorter hospital stays.

• Lower stricture rates: Accurate anastomosis reduces postoperative complications.

Challenges and Considerations

• Steep learning curve for complex biliary reconstruction.

• Longer operative times compared to open surgery initially.

• High cost and limited availability in some centers.

Conclusion

Robotic Roux-en-Y hepaticojejunostomy represents a safe and effective option for managing post-cholecystectomy bile duct injuries. With meticulous preoperative planning, careful dissection, and precise robotic suturing, patients can achieve excellent long-term outcomes with minimal morbidity. As robotic technology continues to evolve, it is likely to become the preferred minimally invasive approach for complex biliary reconstructions.

For more detail log on to: https://www.laparoscopyhospital.com/robotic-surgery.html