Combined robotic cholecystoduodenal fistula repair and hepaticoduodenostomy with bile duct exploration in a patient with recurrent choledocholithiasis and prior Bouveret syndrome: a case report

Introduction

Background

Cholecystoenteric fistula (CEF) is an uncommon complication of chronic gallstone disease. The incidence of CEF has been reported to be as high as 3–5% in patients with cholelithiasis (1). Notably, subtotal fenestrating cholecystectomy may increase the risk of biliary fistulae (2). Up to 70% of these are cholecystoduodenal fistula (CDF), followed by cholecystocolic and then cholecystogastric in frequency (3). CDF typically arises from a large erosive gallstone that compresses the gallbladder wall and, over time, creates a fistulous tract to an adjacent anatomic structure (4-6).

Symptoms are often nonspecific, and may include abdominal pain, fever, weight loss, nausea, vomiting, diarrhea, and in some cases constipation if patient is coursing with a biliary ileus, like in a Bouveret syndrome (4-6). The lack of specific symptoms makes preoperative diagnosis challenging (4-6). Historically, most CDFs were diagnosed intraoperatively during exploration for a separate pathology, limiting appropriate preoperative surgical planning (4-7). Fortunately, with advances in computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP) and endoscopic techniques, the preoperative diagnosis rate now approaches 60% (7,8). While cholecystectomy and fistula takedown are advocated for all by some, others reserve operative management until the patient becomes symptomatic, given factors such as age, technical complexity, and post-operative risk (3,5).

Rationale and knowledge gap

CDF can be managed by either an open or minimally invasive approach—the laparoscopic approach has been described as both safe and feasible in the appropriate patient (1,3,4,6,7). More recently, robotic surgery has gained traction due to the unique advantages of improved vision and instrument articulation (5,9). These benefits have broadened its adoption in the management of various bile duct pathologies, including CDF. Although only a limited number of cases have been published, most reports highlight that robotic surgery can expedite recovery, improve ergonomics and no conversions to open surgery (5,9-13). As in CDF management, robotic surgery has proven to be a safe and effective approach for other complex gallstone diseases, such as bile duct exploration and biliary bypass procedures (9,14,15). Nonetheless, the absence of robust series in robotic management on both conditions makes this manuscript valuable, as it further reinforces current and upcoming knowledge in the use of a robotic platform in complex benign hepaticopancreatobiliary surgery.

Objective

In this paper, we aim to report a rare case of concomitant post-cholecystectomy CDF and RC, both addressed in a single-stage robotic operation, with an uncommon type of biliary bypass; an approach not previously described for surgical treatment of these conditions in the existing literature. We present this article in accordance with the CARE reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-29/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

We present a case of a 71-year-old female with remote history of laparoscopic fenestrating subtotal cholecystectomy for acute cholecystitis. Her past medical history included gastroesophageal reflux, arterial hypertension and breast cancer, for which she completed treatment in June of 2024. In March of 2022, she was diagnosed with a CDF complicated by Bouveret syndrome—duodenal obstruction secondary to a large gallstone, after presenting for vomiting and obstipation. Given her symptoms and no success with an endoscopic approach, an open transgastric stone extraction without fistula takedown was performed. In the following years, the patient experienced multiple admissions, for which she does not recall the details nor has records of them, for episodes of cholangitis and choledocholithiasis, which were managed with antibiotics and endoscopic interventions at outside institutions.

In October 2024, she presented to our clinic for evaluation and possible definitive operative management. Preoperative imaging demonstrated a persistent CDF and 2.6 cm common bile duct (CBD) without residual stones identified (Figure 1). However, in February of 2025, she was admitted to our emergency department with fever, abdominal pain and jaundice. Laboratory testing demonstrated an elevated total bilirubin and leukocytosis. Imaging confirmed cholangitis due to recurrent choledocholithiasis. During this admission, multiple attempts of ERCP were performed (Figure 2) and a plastic stent was placed for an unretrievable 2.5 cm choledocholith, resulting in partial resolution of symptoms.

Figure 1 Coronal view of CT scan demonstrating the CDF (arrows) and clear CBD. CBD, common bile duct; CDF, cholecystoduodenal fistula; CT, computed tomography.

Figure 2 Cholangiogram taken during ERCP showing the 2.5 cm stone (yellow line). ERCP, endoscopic retrograde cholangiopancreatography.

With unsuccessful non-operative management, she re-presented to clinic in March of 2025 to discuss definitive surgical management of the CDF and RC. The plan was for completion cholecystectomy with biliary bypass. The latest preoperative CT scan (Figure 3) re-demonstrated the known 2.5 cm biliary stone, the CDF, and a biliary stent extending up to the cystic duct towards a small remnant gallbladder (Figure 4).

Figure 3 Coronal view of the CT scan. (A) Coronal view of CT scan demonstrating the contracted gallbladder remnant and the CDF (white circle). (B) Coronal view of CT scan demonstrating the 2.5 cm stone in the common bile duct and the biliary stent going up to the cystic duct (white circle). CDF, cholecystoduodenal fistula; CT, computed tomography.

Figure 4 Timeline of events. CBD, common bile duct; CDF, cholecystoduodenal fistula; ERCP, endoscopic retrograde cholangiopancreatography.

Four 8 mm trocars were spaced 7 cm apart across the mid-abdomen, roughly 2 fingerbreadths above the level of the umbilicus. The assistant 12 mm trocar was placed just above the pubis in the midline (Figure 5). After a careful dissection of adherent scar between the omentum, duodenum, and CDF, the remnant gallbladder was identified. Interestingly, the remnant was no longer adherent to the cystic plate; rather, it scarred down on the anterior wall of the second portion of the duodenum. Using blunt dissection, the CDF was identified (Figure 6); however, due to the distorted anatomy, the cystic artery was injured. Bleeding was controlled with a bulldog; the anatomy confirmed, the artery was clipped and divided. The CDF is divided, leaving the visible defect in the duodenum. Further dissection revealed the cystic duct, which was sharply divided, exposing the previously placed biliary stent. The gallbladder remnant was then freed and bagged.

Figure 5 Patient positioning and trocar placement.

Figure 6 Robotic view of the CDF (dashed white oval). CDF, cholecystoduodenal fistula.

In preparation for our reconstruction, a wide Kocher maneuver was performed, and the CBD was circumferentially dissected free from the portal vein. The anterior bile duct is opened to allow retrieval of common duct stones. The CBD was then transected and oversewn distally with a 4-0 V-loc barbed suture. SpyCholangioscopy was performed through the bile duct to rule out residual stones. Given the healthy appearance of the CDF takedown site, the decision was made to re-establish biliary drainage with an end-to-side hepaticoduodenostomy (Figure 7). This was done with two running 4-0 barbed sutures—one for the anterior and one for the posterior layer. The falciform ligament was pedicled and used to bolster the anastomosis, and a 10F flat Jackson-Pratt surgical drain was placed in the retroperitoneum (Video 1). Total operating time was 167 minutes, and blood loss was minimal (<20 mL). An upper gastrointestinal fluoroscopy series showed prompt contrast passage through the duodenum without evidence of leak (Figure 8).

Figure 7 Robotic view of the duodenal wall defect created after transection of the CDF (dashed white circle). CDF, cholecystoduodenal fistula.

Figure 8 Upper gastrointestinal fluoroscopy demonstrated no leak, brisk flow of contrast through the duodenum, and drain in place

Postoperative recovery was uneventful, and the patient was discharged on the second postoperative day. Final pathology revealed chronic inflammatory thickening consistent with fibroelastosis. At 3-month follow-up, the patient remains asymptomatic with normal liver function tests.

Discussion

Key findings

For our patient, preoperative planning centered around completion cholecystectomy and retrieval of a recurrent choledocholith after endoscopic stenting. We approached this case robotically, given the patient’s age, favorable body habitus, and sufficient experience with robotic biliary tract surgery. After tedious fistula takedown and use of SpyCholangioscopy to address the recurrent choledocholith, we were left with a sufficiently long CBD and healthy duodenal os to perform a hepaticoduodenostomy as our biliary tract reconstruction. This would, importantly, allow for to construction of a biliary bypass and address the RC simultaneously. Additionally, it would also allow for future endoscopic interventions; however, to this date, no interventions have been needed, and our patient remains symptom-free.

Strengths and limitations

Cases as the one presented represent a very challenging situation for a surgical team. Addressing both a CDF after a fenestrating cholecystectomy and RC in a single-stage operation requires planning and extensive expertise in biliary surgery, even when an open approach is chosen. With this case, we demonstrated how these complex cases can be addressed robotically, improving not just patient outcomes, such as enhanced recovery, but also facilitating the surgery performance itself.

Nonetheless, there are some limitations regarding this approach. There is no standardized robotic surgical technique, and there are no robust studies regarding outcomes after these types of procedures. Furthermore, access to a robotic platform is a challenge in some settings, making it difficult to acquire the necessary experience in robotic surgery to safely tackle these types of cases.

Comparison with similar research

In order of frequency, biliary bypass procedures for operatively-managed RC include hepaticojejunostomy, side-to-side choledocoduodenostomy, end-to-side hepaticoduodenostomy, and transduodenal sphincteroplasty (14,16,17). While the literature on the optimal reconstructive technique is mixed, surgeon experience often dictates the choice (18-21).

Although laparoscopic biliary reconstructions have been reported for highly-selected patients (17,22-25), there is limited data given the technical difficulty of performing these operations in a narrow working field such as hepatic hilum (9,16). Robotic surgery has emerged as a promising solution to these technical challenges, given the improved ergonomics of the robotic platform. Some studies suggest that robotic surgery may reduce the risk of anastomotic complications compared to a laparoscopic approach (26,27). Other reports have demonstrated the success of robotic surgery in choledocholithiasis management, highlighting its safety, low recurrence rates, and expedited recovery (9,14,15). Our case further reinforces the described benefits of a robotic platform for not only the construction of an end-to-side hepaticoduodenostomy, but also to the meticulous dissection and identification of critical anatomy, afforded by the improved vision and precise instrument control.

While open surgery has historically been the preferred approach to CEF management, minimally invasive techniques are gaining traction, as such in multiple case series (1,3-7). Though these highlight lower post-operative morbidity and mortality rates and hospital lengths of stay, they also admit to high rates of open conversion, 17–80% given the re-operative and densely scarred nature of these cases (3,4,6). Robotic surgery provides additional advantages over the laparoscopic approach, as recent case reports have demonstrated its feasibility and perioperative safety, although the number of published cases remains small (9 patients across these publications) (5,9-13). Notably, none of the authors reported conversions to open, which was attributed to the superior vision and instrument control afforded by the robotic platform (5,9-13). In our reported case, a precise dissection and isolation of the fistula was obtained, making our approach compatible with the benefits described in existing body of literature. Nonetheless, all the cases addressed the CDF by either dividing it with a stapler or cutting it sharply and then primarily closing the defect (5,9-13); none of them used the CDF takedown site as a point for re-establishing biliary drainage with a biliary bypass.

Implications and actions needed

Though promising, the absence of robust series or institutional experience with robotic CDE management underscores the need for individualized decision-making and careful selection process for patients, especially when addressing additional biliary tract pathologies, such as RC. These decisions should be made in the context of the operating surgeon’s experience with complex biliary anatomy surgery and robotic technology.

Conclusions

Our approach demonstrates a tailored surgical strategy for managing complex biliary tract pathologies (CDF and CR), enhanced by the robotic platform. This case highlights the advantages of robotics in vision, ergonomics, instrument control, and patient recovery.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-29/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-29/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-29/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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