Abstract
Introduction:
Hepaticojejunostomy (HJ) is one of the three anastomoses made during a pancreatoduodenectomy (Whipple) procedure. A rare complication of a HJ anastomosis is a stricture formation, which is often symptomatic with pain, jaundice, cholangitis, and potential biliary cirrhosis. 1,2 The recommended initial treatment for HJ stricture is percutaneous dilation. 1,2 Surgical stricture revision is reserved for refractory strictures after failed percutaneous dilations. 2,3 In this video, we describe a robotic approach to revision of a post-Whipple HJ stricture.
Materials and Methods:
A 24-year-old female underwent an open pylorus preserving pancreatoduodenectomy for a solid pseudopapillary tumor of the pancreatic head. Intraoperatively, her bile duct was thin walled and small but a HJ was created. She developed postoperative jaundice from a stricture. Percutaneous transhepatic tube (PTC) was placed across the HJ anastomosis to relieve the jaundice. Subsequently, she underwent multiple percutaneous HJ stricture dilations, over the following year, that were unsuccessful. Cholangiogram a year later showed refractory persistent HJ stricture after attempted removal of the PTC tube. A decision was made to proceed with a robotic revision of the HJ. A robotic camera with three robotic arms and an assistant port were used for the procedure. The omental attachments to the free edge of the right liver were freed until the hepatic hilum was exposed. The jejunal loop anastomosed to the bile duct was identified and dissected from the surrounding attachments until the HJ was circumferentially dissected. The strictured HJ anastomosis was then opened over the indwelling PTC tube. The tube and the associated debris and stones were removed from the bile duct and jejunum. The entire HJ was then divided. The bile duct orifice was examined: it was thick walled and measured 7–8 mm in diameter. The HJ stricture scar was excised completely from the bile duct and jejunal openings. The same jejunotomy was used for reanastomosis. A new HJ was created with running posterior and anterior layers of 4-0 Vicryl sutures on RB-1 needles. The patency of the anastomosis was confirmed using a robotic grasper. The anterior and posterior sutures were then tied, completing the new HJ anastomosis. A surgical drain was placed around the HJ.
Results:
The procedure time was 195 minutes with an estimated blood loss ∼50 mL. The patient had an uneventful recovery postoperatively and was discharged on postoperative day 2. The patient is currently doing well at 9 months postoperatively and will be followed up as needed.
Conclusion:
Robotic HJ stricture revision after previous open pancreatoduodenectomy is feasible. Previous open surgery should not contraindicate an attempt at minimally invasive repair if appropriate minimally invasive surgical and hepatopancreatobiliary (HPB) skills and expertise are available. Robotic surgery provides an increased range of motion/degrees of freedom, reduced surgeon fatigue, and enhanced 3D visualization. Minimally invasive and HPB surgical skills and expertise are necessary to safely perform this procedure. This is often limited to large tertiary HPB surgery centers.
No competing financial interests exist.
Runtime of video: 7 mins 21 secs
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