A narrative review of robotic approaches to bile duct injury: optimizing surgical outcomes

Introduction

Background

Bile duct injury (BDI) is an uncommon but most important complication following cholecystectomy (1) and rarely involves other causes such as blunt abdominal trauma. With over 1.2 million cholecystectomies performed annually in the US (2), this ranges from 0.2% to 0.7% of cases and can cause significant morbidity and potential litigation. Intraoperative detection of BDI necessitates either immediate repair by the surgeon if feasible or more commonly, placement of abdominal drain(s) and transfer to a tertiary center with hepatobiliary (HPB) surgery experience for definitive repair. However, many injuries are detected in delayed fashion post-operatively where patients could present with jaundice, abdominal pain/fullness, fevers and sometimes cholangitis. The timing of repair is debatable based on a variety of factors including the level of inflammation or contamination and generally agreed upon to avoid repair between 2 and 6 weeks from injury. General suggestions are to repair immediately or to wait at least 6 weeks if repaired in delayed fashion as shown in multiple meta-analyses (3,4).

Rationale and knowledge gap

There are several factors that determine the type of repair and reconstruction required following BDI. Initial high quality computed tomography (CT) scan with liver protocol or magnetic resonance imaging (MRI) are required to diagnose the type of biliary injury [according to the Strasberg Classification (5)] (Figure 1) as well as potential liver ischemia due to vasculo-biliary injury (VBI) to the bile duct, hepatic artery and/or portal vein. Once the injury is diagnosed the patients will need biliary decompression, via endoscopic retrograde cholangiopancreatography (ERCP) or via a percutaneous transhepatic cholangiography (PTC) guided biliary drain, with bile duct repair and possible liver resection. In very severe cases with long term secondary biliary cirrhosis some patients may even be candidates for a liver transplant (6).

Figure 1 Injuries to the common hepatic duct. Strasberg Type E1–E5 injuries: E1 (injury >2 cm from hilar confluence); E2 (injury <2 cm from hilar confluence); E3 (injury at the hilar confluence), E4 (destruction of the hilar confluence), E5 (destruction of hilar confluence and aberrant right hepatic duct) (5).

In the past several studies have pointed to a high morbidity rate following open BDI repair with rates above 43%, and median length of stay (LOS) about 9 days (7). Though rare the long term burden from a BDI is high with significant morbidity and mortality in one study approaching 21% (8). Even at 1 year patients had a seven-fold higher mortality with BDI who did not undergo a surgical repair with cumulative costs of emergency room visits increased 2-fold at 1 year if surgical repair is not performed (9). In long term follow-up studies the largest clinical trial of 800 patients with BDI showed a significant loss of quality of life (QoL), loss of productivity in work and disability benefits use (10). Since all these Strasberg Type E1–E5 type BDI require surgical repair, with high long term morbidity and mortality, we should aim to have a very successful single operation. Decreasing the potential morbidity and mortality should be the goal of future BDI repairs. This is where minimally invasive surgical (MIS) techniques may help decrease LOS, decrease surgical morbidity, and increase long term productivity. A small single-center experience of 43 patients showed decreased estimated blood loss (EBL) (51±39 vs. 314±293 mL, P<0.001) and shorter hospital stay (4±1 vs. 16±15 days, P<0.001) with robotic versus open BDI repair (11). However, we need larger multi-center studies to perform multi-variate analysis that can reach statistical significance.

Traditionally with Strasberg A–D injuries most patients could be treated with ERCP or PTBD alone with non-operative management of the biliary injury. However, Strasberg type E (E1–E5) type injuries require a Roux-en-y hepaticojejunostomy and with any concomitant VBI, possible liver resection (12). Such repairs have traditionally been performed with open surgery at high volume tertiary centers due to their complexity. With high definition 4K resolution, 10× magnification, precision range of motion, indocyanine green (ICG) fluoroscopy, and a shorter learning curve compared to advanced laparoscopy, robotic surgery is feasible for these complex repairs (13). Learning the limits of resection and reconstruction requires thorough knowledge of anatomy, surgeon expertise, adequate biliary decompression for control of bile leak and management of potential biliary strictures in the long term.

Objective

In this paper, we aim to describe advanced robotic techniques for BDI repair as well as address any potential limitations using this technology. We provide the current body of evidence from high volume tertiary centers, our own HPB surgical experience with BDI repairs, and provide tools to optimize patient outcomes following repair. We also provide a framework to address current gaps in knowledge using robotic surgery. We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-55/rc).

Methods

We searched on PubMed for original research, literature reviews and meta-analyses between 2015 and 2025 (Table 1). As most comparative safety and efficacy studies between robotic cholecystectomy (RC) and laparoscopic cholecystectomy (LC) matured by 2010 it eventually led to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines for safe LC in 2015 (14). Therefore, our search for BDI repair using robotic approaches was limited to the last 10 years.

Technical considerations and results

Work-up and technical considerations

With the advent of MIS techniques including LC and RC the sheer volume has increased over time. The learning curve has also improved with increased simulation training in robotics. However, the technical considerations based on the difficulty of the case remain. These considerations include a thorough understanding of conventional and aberrant anatomy, possible Mirizzi syndrome, identification of the relevant structures in the OR and using surgical adjuncts like ICG cholangiography (ICGC) to try to prevent injury to the common bile duct. For general surgeons not trained to explore the common bile duct in cases of difficult cholecystectomy the safer approach is usually a subtotal cholecystectomy or a bail out technique such as abdominal drainage to avoid the possibility of a BDI in the first place. Nonetheless, BDI’s do occur in 0.2–0.7% of cases with some studies arguing a slightly higher rate of BDI using RC (15). Given confounders, like the early learning curve and coding variability with robotic surgery since the cohorts were studied [2010–2021], this difference is likely to be negligible between the LC and RC in the future (16). With the advent of robotics there is also a smaller learning curve with simulation training that is allowing surgeons to tackle more complex bilioenteric revision operations (17).

One of the key bottlenecks in caring for BDI following LC or RC is in the early detection. It has been well shown in two large multi-center studies that only up to 44% of BDI were detected intraoperatively with some even more severely injured with VBI in that subset (15%). The two studies show mixed results as well about when to refer to a tertiary center with one showing no difference of when the bilioenteric bypass is done (no difference on complication rate, re-intervention after 90 days or liver related mortality) and conditionally recommended an individualized approach (18). The second paper suggests a repair between 2 and 6 weeks (intermediate period) is a higher risk for complication (19). In one study repair by a non-expert surgeon was the only modifiable risk factor for long term anastomotic stricture formation (20). An international consensus by the International Hepato-pancreatico-biliary Association (IHPBA) cited an early referral (<20 d from injury) to late referral (>20 d from injury) leads to fewer medical malpractice litigations (21). In the late referral group the two modifiable risk factors posing the highest risk of litigation are attempted initial repair before referral [odds ratio (OR) =29.60; P=0.004] and concomitant VBI that was unable to be treated with ERCP or PTC guided biliary drainage resulting in long term complications (OR =10.40; P=0.002). Given the complexity of these injuries, the risk of additional VBI, and lack of expertise outside tertiary HPB/Transplant centers, expedited referral is critical for overall management.

After expedited referral the key to safe repair of BDI is to ensure adequate imaging first, classify the type of injury, and make appropriate decisions prior to repair. For HPB surgeons the best modalities are usually ERCP guided stent or PTC guided biliary drainage that map out the entire biliary tree with high precision cholangiography. Placement of a biliary drain in high Strasberg E type injuries usually is only feasible with PTC guided external biliary drains as the common hepatic duct (CHD) cannot be cannulated adequately to drain bile internally. Once bile spillage is minimized, jaundice improves, and potential cholangitis treated with antibiotics the decision to repair the bile duct can be made. This also depends on the amount of inflammation that would allow a bilioenteric anastomosis to heal properly. If VBI is identified it is commonly the right hepatic artery that is injured and long-term liver injury may ensue. The literature is limited to case reports for robotic hepatectomy in combination with Roux-en-Y hepaticojejunostomy (HJ) (22).

There are some notable contraindications to MIS approaches to BDI repair. The three most important are concomitant VBI as it may require a liver resection as well as bilioenteric bypass and should be approached in an open fashion. If the right hepatic artery is injured there may be some collateralization from the left hepatic artery in the long term, but it depends on anatomic variation and close surveillance imaging. In addition, any injury to the portal vein requires liver resection and many patients need immediate repair with high mortality (12). The second contraindication is the amount of adhesions, difficult anatomy, and intra-abdominal collections that would create a hostile environment for an MIS approach (23). The third contraindication is if there is doubt that the biliary system will not fully drain with the bilioenteric bypass such as from a potential orphan duct. This would lead to recurrent jaundice, necessitate repeated PTC guided procedures and lead to secondary biliary cirrhosis (between 2.4% and 10.9%) potentially requiring a liver transplant in the long term (24).

Technical approaches to robotic BDI repair

We will describe here minimally invasive approaches to Roux-en-y HJ repair, comparing robotic to laparoscopic repairs and the current body of evidence (Table 2). As we can see there is wide variability between laparoscopic and robotic approaches with median follow-up between 9 and 49 months, with overall morbidities between 12.5% and 28.6%. Both approaches have comparably high morbidity and minimal mortality. One newer robotic series by Sucandy shows 50% decrease in LOS compared to most laparoscopic series though this finding should be taken with caution due to small sample sizes. A recent review also highlighted the advantages of robotics vs. laparoscopy in upper gastroenterology (GI) surgery (13). The literature describes a total of less than 10 cases of choledocho-duodenostomy, primary choledocho-choledochostomy, Roux-en-y bi-HJ, the Kasai procedure (Roux-en-y porto-enterostomy) and redo of the jejuno-jejunostomy (unrelated to the HJ) (11). Although these alternate techniques are valid, they are not well powered enough to make a consensus statement.

Our approach to robotic BDI repair

In practice we preferentially obtain both a CTA liver protocol as well as MRCP initially to identify the type of injury and rule out VBI. We then coordinate with interventional radiology (IR) to place one or more PTBD catheters for external drainage. This maximizes bile emptying, minimizes abdominal bile leak, reduces the overall inflammation and we prefer to wait at least 6 weeks from the biliary drainage catheter prior to repair. This ensures minimizing inflammation prior to robotic repair as well as providing a roadmap for adequate repair.

We use a standard 4 supra-umbilical ports in transverse fashion, position the patient in steep reverse Trendelenburg position and dock the robot using the latest DaVinci robotic platform. Instruments we use are hook cautery, scissors, robotic suction, a synchroseal instrument and non-traumatic forced bipolar graspers to handle tissue. We begin by suctioning out any residual collections, then begin with extensive adhesiolysis (Video 1). We expose the length of the CHD while protecting the stomach, duodenum and pancreas inferiorly. We retract the liver up to get adequate exposure to the liver hilum. Next we ensure proper identification of the hepatic artery, right and left as well as any aberrant vessels. We use Firefly ICGC as well to delineate the biliary tree. We also ensure there is no injury to the portal vein. Much of the field may be obscured depending on the number of clips or possibly staples used during the initial cholecystectomy. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Once we have fully exposed the CHD we push forward our PTBD catheters after making a longitudinal choledochotomy (Figure 2). This allows us to cannulate and flush the hilum, the left and right hepatic ducts and make sure we would not need multiple HJ reconstructions in the repair. If the hilum is intact then we measure the length of the CHD for E1–E2 injuries, clean up the duct to a healthy rim of tissue to sew in a Roux limb of jejunum for biliary drainage. The Roux limb is typically 40 cm from the ligament of Treitz and we make our jejuno-jejunostomy first with a standard robotic stapler. We then bring the Roux-limb through a transverse mesocolic defect with care to protect the duodenum and make sure it is a relatively floppy loop for anastomosis. We make an enterotomy in the jejunum and then create a hepaticojejunostomy with a 4-0 slowly absorbable PDS (polydioxane) type suture in running fashion. Before we close the anastomosis fully, we advance the PTBD catheter through it to create an internal stent to protect the anastomosis from leaks. We then flush the catheter to ensure no leak through the anastomosis and suture the PTBD catheter to the skin to secure it. We leave a bulb suction abdominal drain as well outside the anastomosis in case of bile leak. Most patients go home in 3–4 days after we ensure no intraabdominal bile leak, and we discharge home with the PTBD drain (used as in internal stent). We study the PTBD drain with cholangiography in the outpatient setting to ensure there is no delayed anastomotic leak before removing it. In the short term, 1–3 months, we have not had any reported anastomotic strictures using this approach and long-term follow-up is still pending review.

Figure 2 Surgical exposure of the bile duct injury. Blue: stent in the common bile duct. White: percutaneous transhepatic external catheter pulled through the hilar confluence. CBD, common bile duct; CHD, common hepatic duct.

Review of MIS repairs of BDI

There have been two recent meta-analyses of MIS BDI repair studies comparing both robotic and laparoscopic approaches (23,31). Most studies are small cohorts of less than 20 patients and a total of 203 patients with no statistically significant differences between robotic and laparoscopic BDI repairs. However, the pooled studies are informative in comparing the types of injuries repaired, the anastomotic stricture rate, and rate of postop morbidity. There are no reported cases of post-op mortality across all studies. We will need much larger numbers to compare to stricture rate from open bilio-enteric anastomoses (study of 3,300 patients with overall stricture rate of 12%—of which 61.3% benign indications vs. 38.7% malignancy related P<0.02) (32).

Strengths and limitations of robotic BDI repair

With over 1,300 cases reported and the experience with robotic repair ever evolving most surgeons in expert centers already perform robotic reconstruction of the bile duct for many other indications including benign and malignant biliary pathologies. Robotics provides improved visualization, range of motion, smaller learning curve and a growing body of literature for both benign and malignant biliary reconstruction procedures. The robotic approach to BDI seems to be non-inferior to laparoscopic or open BDI repairs in well selected patients (see contraindications above). Robotic simulation training, surgical videos, similar instrumentation and surgical standards in robotic surgery have been widely reported enough to attempt these robotic repairs in a standardized fashion (33). Although there may be a variety of Strasberg type E injuries, most are diagnosed and managed similar to our workup. Operatively, there may be a slight variation in suture technique, drainage catheter use and post-operative follow-up but feasibility has now been shown in several hundred reported cases across many international institutions. Some trends are at least generalizable using robotic BDI repair even if they are not approaching statistical significance.

There are several limitations of these pooled studies of MIS BDI repairs. First the true incidence of BDI is often under-reported and robotic repairs are largely single institution cohorts that are non-randomized and suffer from significant selection bias. Reaching statistically significant conclusions is also difficult as each injury is unique, studies under-powered and the techniques lack granular data to adequately compare outcomes. It is also important to note that some studies do not include long term follow-up of anastomotic stricture or other long-term complications with standard intervals. Strictures form anywhere between 11 and 30 months in the largest study, but many included studies did not report their stricture rate (24). All centers are specialty high volume centers but we lack patient specific factors in many of these studies as well such as possible VBI, whether suspected or explicitly ruled out.

Conclusions

Robotic repair of BDI is feasible and have been shown to be as effective as laparoscopic repairs with outcomes that are comparable. Precise diagnosis, multi-disciplinary management with IR and GI interventions, timing of surgery, robotic surgical expertise to create bilio-enteric anastomosis and preventing missed injuries are critical to long term outcomes. This includes preventing bile leaks/bile sepsis, preventing anastomotic strictures and secondary biliary cirrhosis. Future studies may provide larger cohorts, with propensity matched controls and provide standardized algorithms for robotic repair. However, all surgical outcomes are only as good as those who perform them with adequate surgical expertise in HPB surgery.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-55/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-55/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-55/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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