Minimally invasive surgery for post cholecystectomy biliary stricture: current evidence and future perspectives

Postcholecystectomy bile duct injury (BDI) remains a devastating iatrogenic complication that adversely impacts the quality of life with high healthcare costs. Despite a decrease in the incidence of laparoscopic cholecystectomy-related BDI, the absolute number remains high as cholecystectomy is a commonly performed surgical procedure. Open Roux-en-Y hepaticojejunostomy with meticulous surgical technique remains the gold standard surgical procedure with excellent long-term results in most patients. As with many hepatobiliary disorders, a minimally invasive approach has been recently explored to minimize access-related complications and improve postoperative recovery. Since patients with gallstone disease are often admitted for a minimally invasive cholecystectomy, laparoscopic and robotic approaches for repairing postcholecystectomy biliary stricture are attractive. While recent series have shown the feasibility and safety of minimally invasive post-cholecystectomy biliary stricture management, most are retrospective analyses with small sample sizes. Also, long-term follow-up is available only in a limited number of studies. The principles and technique of minimally invasive repair resemble open repair except for the extent of adhesiolysis and the suturing technique with continuous sutures commonly used in minimally invasive approaches. The robotic approach overcomes key limitations of laparoscopic surgery and has the potential to become the preferred minimally invasive approach for the repair of postcholecystectomy biliary stricture. Despite increasing use, lack of prospective studies and selection bias with available evidence precludes definitive conclusions regarding minimally invasive surgery for managing postcholecystectomy biliary stricture. High-volume prospective studies are required to confirm the initial promising outcomes with minimally invasive surgery.