How I Do It: Simplified Transcystic Antegrade-only Robotic Common Bile Duct Exploration (RCBDE)

Abstract

BACKGROUND: Data consistently supports a surgery-first approach to common bile duct (CBD) stones in patients with a gallbladder via laparoscopic CBD exploration (LCBDE). LCBDE has equivalent efficacy and decreased cost as compared with cholecystectomy plus endoscopic retrograde cholangiopancreatography (ERCP). However, adoption has been low due to the technical limitations of laparoscopy. We describe a straightforward and highly reproducible robotic CBDE (RBCDE) technique. METHODS: A cystic ductotomy is made after obtaining a critical view of safety. Through a 5 mm port, a wire-ready cholangiogram catheter is secured in the cystic duct and intraoperative cholangiogram performed. Based on stone burden, small versus large, either an antegrade balloon snowplow (push stones forward) or sphincteroplasty is performed over a wire under fluoroscopy. If concern persists for retained stones, choledochoscopy is performed. CONCLUSIONS: Our simplified antegrade-only RCBDE technique allows surgeons to consistently offer a surgery-first, single-stage approach to CBD stones in patients with a gallbladder.