Bile duct injury is a rare complication in the modern era of minimally invasive laparoscopic and robotic surgery; however, it can lead to serious short- and long-term consequences. Repair of bile duct injury with Roux-en-Y hepaticojejunostomy is a technically complex operation, especially when undertaken laparoscopically. Newer robotic technology improves surgeon\'s dexterity for fine suturing tasks such as in creating a delicate hepaticojejunostomy, which overcomes technical limitations of conventional laparoscopic approach. As surgeons accumulate more experience in minimally invasive bile duct surgery for benign and malignant diseases, the accepted surgical approaches gradually transition from open to robotic technique. In this video, we describe our robotic technique for delayed repair of an E2 bile duct injury.

Impact of timing of repair on outcomes of patients repaired with Hepp-Couinaud hepatico-jejunostomy (HC-HJ) after bile duct injury (BDI) during cholecystectomy remains debated. This is an observational retrospective study at a tertiary referral hepato-biliary center. HC-HJ was always performed in patients without sepsis or bile leak and with dilated bile ducts. Timing of repair was classified as: early (≤ 2 weeks), intermediate (> 2 weeks, ≤ 6 weeks), and delayed (> 6 weeks). 114 patients underwent HC-HJ between 1994 and 2022: 42.1% underwent previous attempts of repair at referring institutions (Group A) and 57.9% were referred without any attempt of repair before referral (Group B). Overall, a delayed HC-HJ was performed in 78% of patients; intermediate and early repair were performed in 17% and 6%, respectively. In Group B, 10.6% of patients underwent an early, 27.3% an intermediate, and 62.1% a delayed repair. Postoperative mortality was nil. Median follow-up was 106.7 months. Overall primary patency (PP) attainment rate was 94.7%, with a 5- and 10-year actuarial primary patency (APP) of 84.6% and 84%, respectively. Post-repair bile leak was associated with PP loss in the entire population (odds ratio [OR] 9.75, 95% confidence interval [CI] 1.64-57.87, p = 0.012); no correlation of PP loss with timing of repair was noted. Treatment of anastomotic stricture (occurred in 15.3% of patients) was performed with percutaneous treatment, achieving absence of biliary symptoms in 93% and 91% of cases at 5 and 10 years, respectively. BDI can be successfully repaired by HC-HJ regardless of timing when surgery is performed in stable patients with dilated bile ducts and without bile leak.

Minimally Invasive bile duct repair is an emerging modern technique in hepatobiliary surgery. Conventional laparoscopic technique had been sporadically reported by high volume surgeons as an alternative to open operation, however, the majority of those repairs were undertaken for biliary injury below the biliary bifurcation. Roux-en-Y Hepaticojejunostomy below the biliary bifurcation is technically much simpler to complete when compared to that above the hilar plate (high bile duct injury). The risk of long-term anastomotic stricture is also higher as bile duct caliber decreases. This is anatomically inherent as we travel further cranial beyond the hilar plate. In this multimedia article, we describe our minimally invasive technique for high bile duct injury repair using robotic technology.

BACKGROUND: Mexican health system structure allows us to study the differences in bile duct injury (BDI) management. The study aimed to assess the differences in patients with complex BDI in 2 different public sector institutions using a new proposed standard terminology.
METHODS: Retrospective review (2008-2019) in 2 public institutions (IMSS/SESVER). Bismuth-Strasberg E injuries with hepaticojejunostomy were included. Data are presented in a tabular reporting system. The outcomes were percent of patients attaining primary patency, loss of primary patency, and actuarial primary patency rate.
RESULTS: Seventy-eight patients (IMSS: n = 37; SESVER: n = 41) without differences in demographic and preoperative assessment were studied. BDI occurred mostly in outside hospitals. Open cholecystectomy was the most common index operation in SESVER (73%, p = 0.02). IMSS had more surgeries (p = 0.007) and repair attempts (p = 0.06) prior to referral. Magnetic resonance cholangiopancreatography was more commonly used in IMSS patients. Biliary stents (45%) and cholangitis (29%) were more common in IMSS (p < 0.05). IMSS patients had longer follow-up than SESVER (p < 0.05). No differences in primary patency rates (IMSS: 89%, SESVER: 97%) and actuarial patency rates were noted.
CONCLUSIONS: Despite differences in referral, preoperative, and operative events, good BDI repair outcomes can be achieved. Longer follow-up is needed to monitor these outcomes.