Commentary on Brief Clinical Report: Reconstruction/Repair of Iatrogenic Biliary Injuries
Despite consistently excellent results in the repair of major bile duct injuries (BDIs) reported at academic centers, these injuries remain devastating to patients, young and old. Factors such as suffering a major complication with one or more hospitalizations following what was viewed as a “routine outpatient procedure”; a large incision, often with the need for drains or stents; a prolonged recovery, with time away from work and family, makes this complication among the most difficult for patients to understand or accept. Therefore, it is not surprising that BDIs are a common cause of medical malpractice litigation and often result in substantial payment to the plaintiff.
Would not it be great if there was a minimally invasive method to repair a BDI that could be accomplished early after the injury and have excellent long-term results. Unfortunately, these operations are often technically challenging requiring meticulous dissection and reconstruction, often deep in a small field with inflammation associated with an ongoing bile leak. It would seem unlikely that any laparoscopic approach would be technically possible. Thus, the report by Giulianotti et al at the University of Illinois in Chicago of 14 successful robotic repairs of BDIs is most impressive. The series was accomplished without conversion and the majority of cases were completed in the first 2 weeks following the injury. They reported minimal complications, a reasonable length of stay, and no readmissions or reoperations. The long-term results at a mean of follow-up approaching 3 years would appear comparable to those results observed following open repair. Very impressive results, regardless of the operative technique.
So, how to put these excellent results into perspective? It should be noted that the lead author and his entire institution has been on the cutting edge of innovative robotic surgery for well over a decade. The multiple series of robotic procedures reported by this group is impressive, and therefore, it comes as no surprise to see such excellent results with robotic repair even in this complicated setting. But in reality, there are few groups around the world who would even try such a procedure, let alone replicate these results. Therefore, widespread applicability of robotic repair of BDIs is unlikely at this time. This report however does offer hope that someday, hopefully soon, computer-guided technology in surgery with well-trained surgeons willing to take on innovative procedures may provide short- and long-term advantages for our patients. Such techniques may not just be accomplished with traditional measures of success including with minimal morbidity and mortality and excellent long-term results, but offer better quality of life and psychological benefits to patients. It is unclear whether these benefits will translate into avoidance of lawsuits, but it would certainly seem that eliminating some of the trauma and devastation associated with these injuries might offer hope on this front as well.