[Robotic Management of a Bile Leak After Cholecystectomy Caused by an Aberrant Bile Duct of the Hepatic Segments, Using a Combined Biliodigestive Anastomosis Incorporating the Cystic Duct Stump].
Hochstein Jan Niklas JN, Umstadt Julia J, Neesse Albrecht A, Egberts Jan Hendrik JH
Bile leaks are serious complications after cholecystectomy. Their management is usually individualised and requires interdisciplinary surgical and endoscopic expertise. In cases of leaks caused by aberrant bile ducts, closure of the leak may be impossible-depending on the size of the drained liver area; therefore, drainage-e.g., by means of a biliodigestive anastomosis-is required. We report the case of a 66-year-old female patient referred from an external hospital with a bile duct leak caused by an aberrant bile duct of segments V and VIII and concomitant cystic duct stump insufficiency following laparoscopic cholecystectomy. Due to the extent of the drained liver area, surgical management with drainage of the bile duct was pursued. Preservation of the option for ERCP in the event of potential secondary complications, such as bile duct strictures, was considered important. Given the prior laparoscopic surgery, a minimally invasive approach was favoured. A robot-assisted exploration of the hepatic hilum and bile ducts was performed. Primary anastomosis was not feasible, due to the distance between the structures. For drainage of the bile duct, a combined anastomosis was created: the cystic duct stump was anastomosed to the aberrant bile duct on the posterior wall, and a biliodigestive anastomosis using a Roux-en-Y reconstruction was performed on the anterior wall. Intraoperatively, a biliary stent was placed via the cystic duct stump into the aberrant bile duct. The postoperative course was uneventful, with no recurrence of the bile leak. The patient was discharged after 11 days. The biliary stents were removed after 7 weeks, demonstrating good contrast drainage from the aberrant bile duct into the biliodigestive anastomosis. Robot-assisted management of bile duct injuries should be considered in patients with prior laparoscopic surgery. Roux-en-Y reconstruction incorporating the cystic duct stump to preserve the option of ERCP is a viable treatment strategy for leaks originating from larger aberrant bile ducts.