Intraoperative Video Consultation Following Bile Duct Transection Facilitates Direct OR Transfer for Robotic Hepaticojejunostomy at Tertiary Center

Here we present an intraoperative video consultation that facilitated same-day repair of a bile duct injury during the COVID pandemic. The patient is a 63-year-old male with a history of coronary artery disease with stent placement four years prior, COPD, and diabetes. He initially presented with a three-month history of right upper quadrant abdominal pain associated with meals.

Imaging revealed cholelithiasis. The patient was taken for an elective laparoscopic cholecystectomy at a rural hospital. During the surgery, the surgeon recognized a complete transection of the bile duct three centimeters from the bifurcation.

While still in the OR, the surgeon consulted our HPB surgeon on call via video. This consultation was approved, which allowed not only discussion but also visualization of the patient's anatomy and duct injury. We recommended a cholangiogram at the time to confirm our suspicions.

Here you can see the duct is transected just distal to the bifurcation. We were able to visualize this via video and accept for transfer. However, given the rural setting of the hospital, an ambulance was not immediately available for transfer.

Therefore, we recommended closing the patient and obtaining a CTA, which confirmed no concomitant vascular injury. Additionally, as a result of the COVID pandemic, our hospital was at full capacity with most direct admissions being delayed three days. Because of this significant delay and the unique consultation allowing us to orchestrate the appropriate workup remotely, we decided to accept the patient as a direct transfer to the operating room, which allowed him to be transferred immediately.

The patient was positioned on a split leg table with his arms out. The abdomen was entered with an optical separator device, CO2 was insufflated, and the abdomen was explored. Four robotic ports and two assistant ports were inserted, as seen in the figure.

The patient was placed in reverse Trendelenburg with his right side up. The liver was retracted cranially using a flexible flank right liver retractor. The recent cholecystectomy site was evaluated and the transected biliary structure was identified.

The distal bile duct was over sewn using 2/0 silk figure of eight sutures. The proximal duct was trimmed with cold scissors with active bleeding at the cut edge, signifying perfusion for anastomotic healing. Here you can see the proximity to the bifurcation.

The ligament of Treitz was identified and the proximal jejunum was followed 40 centimeters distally, where a loop of jejunum was identified as a site for the future anastomosis with the bile duct. Using a vessel seal device, a mesenteric window was created and the bowel was divided with a 60-millimeter Purple Load Endo GIA stapler. The vessel sealer device was used to divide the mesentery, taking care to avoid mesenteric vasculature.

A silk suture is used to mark the site of the future jejunojejunostomy. A retrocolic tunnel was created in the mesentery of the transverse colon using blunt dissection. The Roux limb was then subsequently passed through this space into the lesser sac and the jejunum reached the anastomotic site without tension.

Using cauterized scissors, an enterotomy is created in the Roux limb at the site of the anastomosis. Two 4/0 V-Loc sutures were then anchored at the corner of the enterotomy on the antimesenteric aspect of the jejunum. The first V-Loc suture will run along the posterior wall of the anastomosis while the second V-Loc suture will run along the anterior side where the two sutures will meet.

The hepaticojejunostomy anastomosis was then performed in an end-to-side duct-to-mucosa fashion, as each V-Loc suture was run along either side of the enterotomy. Here you can see the posterior suture being run on the anastomosis, in to out on the duct and out to in on the jejunum. A 4-French Hobbs stent was placed into the duct to facilitate reconstruction and ensure patency during creation of the anastomosis.

This helped protect the posterior wall while sewing anteriorly. Once the stent was in place, we continued sewing in a running manner with the first suture. We then transitioned to sewing with a second V-Loc suture, again in a running manner.

On the anterior wall of the anastomosis, the V-Loc suture is run out to in on the duct and in to out on the jejunum. Once the two sutures met, they were tied together to complete our end-to-side duct-to-mucosa hepaticojejunostomy. Here is the completed anastomosis.

The neo-gastrointestinal anatomy was confirmed by tracking the jejunum limbs. Small enterotomies were created near the previous stapled edge of the jejunum and a segment more distal at the Roux limb approximately 50 centimeters. A 60-millimeter Purple Load Endo GIA staple fire was then used to create a side-to-side jejunojejunostomy.

The common enterotomy was closed with 3/0 V-Loc sutures followed by interrupted 3/0 silk Lembert sutures. 3/0 silk sutures were again used to close the colon mesenteric defect. Finally, a round Blake drain was placed at the site of the hepaticojejunostomy.

The patient is now three years post-op without complaints. We present this case as an example of how intraoperative video consultation can be used to recommend appropriate workup and aid orientation to the injury and situation, therefore improving transfer of care, minimizing duplicated or unnecessary workup and unnecessary delays. Commonly, a consult for bile duct injury is called after the patient is already in recovery, even if the injury was identified intraoperatively.

However, completing the consult intraoperatively via video allowed an enhanced level of communication between surgeons. Our surgeon was able to better evaluate the needs of the patient and required diagnostic workup. As previously mentioned, if this degree of information had not been available, it would not have been appropriate to transfer the patient directly to the operating room and, thus, because the maximum capacity of the hospital secondary to COVID, the patient would likely have not been transferred for several days, complicating management.

In conclusion, intraoperative video consultation should be considered at a time of bile duct injury to improve provider communication and expedite care.