V6. Robotic end-to-side hepaticojejunostomy anastomosis using running barbed suture and associated long-term biliary complications

Introduction: Robotic pancreaticoduodenectomy continues to emerge as a safe and feasible option for oncologic treatment of patients with malignancies of the head of the pancreas. Various approaches to creation of the hepaticojejunostomy robotically have been described but long-term data on technical and operative outcomes is lacking.

Methods: We demonstrate our robotic running technique for an end-to-side hepaticojejunostomy using 2 barbed sutures in two representative operative cases. Furthermore, we retrospectively reviewed our prospectively maintained database of subjects who underwent robotic pancreaticoduodenectomy at our institution between 2013-2025. Patients were excluded if the case was converted to open. All complications related to the hepaticojejunostomy were identified.

Results: Patient A is an 87-year-old female diagnosed with an ampullary adenoma not amenable to endoscopic resection identified on work up for dysphagia. Patient B is a 72-year-old female who presented with painless jaundice requiring ERCP and metal stent placement in setting of a resectable head of pancreas adenocarcinoma. Both patients underwent R0 resections and had uneventful recoveries postoperatively. Between 2013 and 2025, 163 robotic pancreaticoduodenectomies have been performed at our institution. The majority of patients (63, 39%) were diagnosed with head of pancreas intraductal papillary mucinous neoplasm meeting guideline definitions for resection based on high-risk stigmata or worrisome features. 35 (21%) patients in the cohort were diagnosed with resectable head of pancreas adenocarcinoma. Over the 12-year period, we identified 10 (6%) complications specific to the hepaticojejunostomy including 4 (2%) bile leaks and 4 (2%) biliary strictures. Median time to stricture formation was 5 years (range 6 days - 6 years). Two (1%) patients formed secondary biliary stones at 6 and 11 years after resection. These complications were managed with a combination of endoscopic retrograde cholangiopancreatography and percutaneous transhepatic drain placement.

Conclusions: Hepaticojejunostomy anastomosis can safely be reconstructed robotically using a running end-to-side technique with barbed suture and is associated with low rates of short-term and long-term complications.