Hepaticojejunostomy bile leakage and aberrant biliary anatomy during robotic pancreatoduodenectomy: intraoperative detection and management

BACKGROUND: Bile leakage from the hepatico-jejunostomy (HJ) is a rare but potentially lethal complication during robotic pancreatoduodenectomy (RPD). The rate of intraoperatively detected bile leakage from the HJ and aberrant biliary anatomy during RPD and its optimal management remains unclear. METHODS: This retrospective and exploratory cohort study included all adult patients undergoing RPD at a single high-volume center (December 2018-March 2025). Standardized operating reports were reviewed regarding: (a) intraoperative bile leakage observed during the routinely performed 'HJ gauze test,' (b) multiple HJ anastomoses, (c) joined bile ducts, or (d) placement of a HJ stent. Bile leakage was managed intraoperatively by additional direct sutures or, if not deemed safe, by anchoring sutures between the jejunum and the hilar plate. Only ISGLS bile leakage grade B/C was included. RESULTS: Overall, 238 patients undergoing RPD were included. The routinely performed intraoperative 'HJ gauze test' detected bile leakage in 21 (9%) patients, all of whom underwent intraoperative surgical repair: 13 (62%) direct sutures and 8 (38%) anchoring sutures to the hilar plate. In these patients, postoperative bile leakage occurred in 3/21 (14%) patients with 0/21 (0%) mortality. Overall, 5 (2%) patients received two HJs, and 8 (3%) patients received a stent in the HJ with 0/11 (0%) bile leakage. Patients with intraoperative findings of bile leakage had a non-significant higher rate of postoperative bile leakage (3 patients [14%] vs 12 patients [6%]) (OR 2.83, 95% CI 0.47 to 11.91, Fisher's exact test p = 0.12). CONCLUSION: Routine use of the 'HJ gauze test' during RPD may be useful to detect intraoperative bile leakage, with similar outcomes after intraoperative repair (either with direct sutures or anchoring sutures). Non-standard HJ constructions and bile duct anatomy variants were rare.