Robotic-Assisted Transcystic Endoscopic Common Bile Duct Exploration

Abstract

Choledocholithiasis complicates cholecystectomy in 10–15% of patients. In individuals with prior Roux-en-Y gastric bypass (RYGB), altered foregut anatomy renders traditional endoscopic retrograde cholangiopancreatography (ERCP) technically challenging or unsuccessful. This report details the use of robotic-assisted transcystic endoscopic common bile duct exploration (TCBDE) in a patient with RYGB and choledocholithiasis. For patients with surgically altered anatomy and urgent need for stone clearance, robotic TCBDE represents a safe, cost-effective, single-stage alternative to two-stage approaches, effectively bypassing the anatomical limitations imposed by RYGB.

Keywords

Transcystic endoscopic common bile duct exploration; choledocholithiasis; cholecystectomy.

Case Overview

Background

Choledocholithiasis is a prevalent condition that complicates the management of approximately 10–15% of patients undergoing cholecystectomy for uncomplicated, symptomatic cholelithiasis.¹ The conventional management of these patients often involves a two-stage approach utilizing preoperative or postoperative endoscopic retrograde cholangiopancreatography (ERCP) in conjunction with laparoscopic cholecystectomy. While ERCP is highly effective for biliary clearance in standard anatomy, it presents significant challenges in patients who have previously undergone bariatric procedures such as Roux-en-Y gastric bypass (RYGB).
The rapid weight loss associated with gastric bypass surgery inherently increases the incidence of gallstone formation.² However, the surgical alteration of the foregut anatomy restricts traditional endoscopic access to the biliary tree. This led to the development of several novel techniques including laparoscopic trans-gastric ERCP, EUS-assisted ERCP, double-balloon ERCP, and minimally invasive transcystic common bile duct exploration.^3–6

Focused History of the Patient

The patient is a 69-year-old male with past medical history significant for class III obesity who underwent RYGB approximately 10 years prior to presentation. He initially presented to an outside hospital with choledocholithiasis. There, an ERCP was initially attempted but could not be completed due to bypass anatomy. He therefore underwent percutaneous cholecystostomy tube placement with plans for lithotripsy once a tract is well epithelialized in 4–6 weeks. Unfortunately, the patient presented again approximately two weeks later with worsening abdominal pain, leukocytosis, hyperbilirubinemia, and gram-negative bacteremia due to biliary drain occlusion. Although his condition improved with drain flushing, he was transferred to our institution for further management. Given the inability to clear the ducts previously through ERCP, the patient was offered robotic cholecystectomy with transcystic endoscopic common bile duct exploration. He was diagnosed postoperatively with cirrhosis based on the appearance of his liver intraoperatively, and the presence of ascites on postoperative imaging. This was confirmed with a transjugular liver biopsy. His MELD score in the postoperative period was 21.

Physical Exam

The physical exam was significant for jaundice visible on the patient's skin, sclera, and soft palate. He also sustained mild right upper quadrant tenderness.

Imaging

Computed tomography (CT) of the abdomen revealed adequate position of the percutaneous cholecystostomy tube but with ongoing choledocholithiasis with intra- and extrahepatic biliary dilation.

Treatment Options

For choledocholithiasis in the setting of RYGB, the patient had several treatment options. These include: open common bile duct exploration, cholecystectomy with gastrostomy placement for future ERCP, percutaneous endoscopic biliary lithectomy (PEBL) through the percutaneous cholecystectomy tube, laparoscopic transgastric ERCP, EUS-assisted ERCP, double-balloon ERCP, and minimally invasive transcystic common bile duct exploration.

Rationale for Surgical Treatment

Given failure to adequately decompress the biliary tree with percutaneous cholecystectomy and progression to bacteremia and possible ascending cholangitis, the patient needed stone clearance in a more urgent fashion. Given concern for underlying cirrhosis, a less invasive option was preferred. However, he was not a candidate for PEBL given ongoing cholangitis without adequate time for the tract to form. During the consent process, the patient was offered robotic-assisted cholecystectomy with choledochoscopy and lithotripsy. He was also informed about the potential failure to fully clear the biliary tree which would ultimately require gastrostomy tube placement and possible on-table or future ERCP for biliary clearance.

Discussion

The management of common bile duct stones is characterized by a continuous drive toward anatomical preservation and minimization of procedural trauma. Historically, open cholecystectomy paired with open common bile duct exploration was the definitive standard of care. The advent of laparoscopic cholecystectomy in the late 1980s revolutionized the management of gallbladder disease. This introduced the new challenge of concomitant choledocholithiasis through minimally invasive means. Initially, the field shifted heavily toward a two-stage approach utilizing ERCP. Over time, the intrinsic limitations of ERCP, including the risk of postprocedural pancreatitis, sphincter of Oddi destruction, and the physiological burden of multiple anesthesia events, catalyzed the development of single-stage laparoscopic interventions.⁷ Laparoscopic transcystic common bile duct exploration emerged as it utilizes the existing anatomical conduit of the cystic duct to access and clear the biliary tree without necessitating a formal choledochotomy.

Laparoscopic transcystic common bile duct exploration is primarily indicated when common bile duct stones are confirmed during laparoscopic cholecystectomy via intraoperative cholangiography or ultrasound. The transcystic route is particularly favorable and indicated for patients with a stone burden of fewer stones, stones smaller than 10 mm in diameter, and a cystic duct caliber of 4 mm or greater.⁸ Furthermore, altered gastrointestinal anatomy, such as a prior RYGB, serves as a strong indication for this approach due to the technical difficulties of performing a traditional ERCP.⁹

Dedicated reusable choledochoscopes, digital ureteroscopes, or disposable single-use scopes such as the Boston Scientific Spyglass Discover scope (Boston Scientific Corp., Boston, MA, USA) are all reasonable scope options that provide direct endoscopic visualization of the duct as well as a working channel that can deliver instruments such as lithotripsy probes, baskets, and wires. Surgeons providing this service should be familiar with what their institution has available in terms of both endoscopes and endoscopic instruments. We routinely use the SpyGlass Discover scope due to its ease of use, sterile packaging, digital imaging, and our familiarity with the device.

Several alternative approaches have been developed for management of choledocholithiasis in patients with RYGB anatomy. Laparoscopic-assisted ERCP (LA-ERCP) combines laparoscopic access to the excluded stomach with conventional ERCP and has historically been considered a reference standard, achieving technical success rates exceeding 95%.^3–6 More recently, EUS-directed transgastric ERCP (EDGE) has emerged as a minimally invasive alternative. EDGE creates a temporary gastrogastric fistula using a lumen-apposing metal stent, permitting conventional ERCP access to the biliary tree.^10,11 Multiple studies have demonstrated technical and clinical success rates comparable to LA-ERCP while potentially reducing procedural complexity and resource utilization.^10–12 Nevertheless, concerns remain regarding persistent fistula formation and stent-related adverse events.¹²

EUS-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTBD) provide additional options when conventional biliary access cannot be achieved. EUS-BD offers internal biliary decompression through hepaticogastrostomy or choledochoduodenostomy and has demonstrated high technical and clinical success rates in expert centers.^13,14 Compared with PTBD, EUS-BD may provide similar efficacy while reducing adverse events and while avoiding the need for external drainage catheters.¹⁴ PTBD remains an effective rescue technique, particularly in patients with acute cholangitis or those unsuitable for endoscopic intervention; however, external drainage catheters can negatively affect quality of life and often require repeat interventions.^13,14

Despite its efficacy, there are distinct absolute and relative contraindications to the transcystic approach. The presence of stones larger than 1 centimeter in diameter or a high stone burden of ten or more stones typically contraindicates the procedure, as these factors significantly increase operative time and the risk of ductal trauma or retained fragments.⁸ Stone location is equally critical; stones situated in the common hepatic duct or proximal to the cystic duct insertion are more difficult to clear via the transcystic route.

When appropriately applied, the success rates for laparoscopic transcystic common bile duct exploration are excellent, typically ranging from 85–95%.¹⁵ The procedure is consistently shown to be more cost-effective than postoperative ERCP, largely due to a reduction in cumulative hospital stay and the avoidance of secondary procedural fees.^16,17 When transcystic clearance fails, surgical alternatives such as laparoscopic choledochotomy, common bile duct exploration, or postoperative endoscopic management must be employed to ensure complete biliary clearance.

We chose to use the robotic platform in this case due to its availability, though a laparoscopic approach would have been equally effective. Some may argue that the robotic platform provides improved visuals, more stable control when doing technically advanced procedures, and decreased physical stress and fatigue during longer more arduous cases, but the clinical outcomes between robotic and laparoscopic cholecystectomy with common bile duct exploration have not been reported. Anecdotally, the operating surgeon should be aware that working at the bedside with the robot boom deployed can be somewhat cumbersome as it requires you to work around the robotic arms. Depending on the institution, there may be differences in availability as well as cost and this should be considered when deciding on the operative approach.

Equipment

• Da Vinci Robotic System Xi
• SpyGlass DS Direct Visualization System

Disclosures

Winder: Boston Scientific Corp. Consulting fees.

The authors report no other conflicts of interest, financial relationships, funding, sponsorship, equipment support, or other relationships that could be perceived to influence the content of this article.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.