The present case illustrates the role of robotic surgery in managing complex and difficult choledocholithiasis in a patient with surgically altered upper gastrointestinal anatomy. Conventional ERCP was technically unfeasible because the major papilla could not be reached, despite endoscopic identification and traversal of the afferent limb, in the setting of a Billroth II-type reconstruction, non-traversable pyloric stenosis, and markedly distorted duodenal anatomy. DAE-ERCP represented a potential alternative for the surgically altered anatomy but was not available, while EUS-guided biliary drainage with antegrade treatment was not pursued because of the complex anatomy and available local expertise. Following unsuccessful percutaneous mechanical stone extraction, the multidisciplinary discussion focused on percutaneous cholangioscopy-guided lithotripsy, followed by delayed cholecystectomy, versus definitive single-stage surgical treatment. The latter was selected to address both the gallbladder and CBD stones during the same procedure. Given the institutional expertise in robotic surgery, this approach was chosen to facilitate precise dissection and biliary exploration in this complex anatomical setting through enhanced dexterity, three-dimensional visualization, and tremor filtration. The total operative time was 430 min and should be interpreted in the context of the exceptional technical complexity of this case rather than as an expected duration of robotic CBDE. The procedure required extensive adhesiolysis following previous open abdominal operations, careful dissection of large duodenal diverticula that were densely adherent to the hepatic hilum, and management of markedly distorted biliary anatomy. In addition, several sequential intraoperative modalities were required to achieve and confirm ductal clearance, including IOUS, external ductal manipulation, irrigation, Fogarty balloon extraction, choledochoscopy with repeated basket retrieval attempts, robotic intraductal grasping, primary closure of the choledochotomy, and intraoperative cholangiography. Complete ductal clearance was defined intraoperatively by concordant findings from direct choledochoscopy, IOUS, and cholangiography. Specifically, final choledochoscopy demonstrated no visible residual stones or fragments, IOUS showed no residual intraductal stones, and cholangiography demonstrated no persistent intraluminal filling defects together with free passage of contrast into the duodenum. Cholangiography additionally confirmed the absence of contrast extravasation from the biliary tree. The complete sequence of preoperative imaging, intraoperative assessment, stone extraction, and confirmation of ductal clearance is documented in the accompanying Video Abstract. The patient experienced an uneventful recovery. These outcomes can be attributed to careful preoperative planning and effective multidisciplinary collaboration, both pre- and intraoperatively [3].

Currently, there is no standardized protocol for selecting robotic CBDE. However, guidelines recommend surgical CBDE in cases defined as “difficult CBDSs” because it remains a rescue treatment when endoscopic attempts fail [4,5,6]. ESGE guidelines define “difficult CBDSs” as stones with a diameter > 1.5 cm, multiple or barrel-shaped stones, an intrahepatic or cystic duct location, impaction, altered anatomy, distal bile duct angulation <135°, sigmoid-shaped CBD, and short-length ducts [5]. Two conventional surgical approaches exist for CBDE: the transcystic (TC) and transductal (TD) routes. Larger stones (>6 mm), small cystic ducts (<4 mm), intrahepatic stones, and distal or posterior cystic duct insertion into the CBD are associated with poor TC success rates, favoring the TD approach [14].

Minimally invasive CBDE has been explored predominantly through studies assessing the laparoscopic approach, which have evidenced its feasibility and safety [8]. However, laparoscopic techniques present limitations, including two-dimensional vision, lack of depth perception, reduced degrees of freedom of instruments, and the fulcrum effect, which creates a disparity between visual feedback and proprioceptive function [15]. Robotic-assisted choledochotomy and CBDE may overcome many of these disadvantages. In our experience, the robotic system allowed complex intraoperative maneuvers for CBD exploration, such as the choledochoscopy-guided robotic intraductal grasping maneuver, which is not otherwise feasible without articulating instruments. Previous descriptions of robotic common bile duct exploration have reported choledochoscopy-assisted stone extraction, predominantly using retrieval baskets introduced through the working channel of the choledochoscope, as well as lithotripsy followed by flushing or basket retrieval [10,12]. In the present case, repeated choledochoscopic basket attempts failed because the residual stone was firmly impacted at the cystic duct–CBD junction and could not be adequately captured. The rescue maneuver used in this case differs technically from conventional choledochoscopic basket retrieval. The 3.2-mm choledochoscope, with its 1.2-mm working channel, was used to provide continuous intraductal visualization, whereas an 8-mm wristed robotic Fenestrated Bipolar Forceps was introduced independently through the approximately 30-mm choledochotomy. The forceps was articulated to achieve near-coaxial alignment with the CBD and advanced under direct choledochoscopic control. This configuration allowed the instrument to obtain direct mechanical purchase on the exposed surface of the impacted stone without requiring circumferential deployment of a basket around it. Bipolar energy was never activated during intraductal manipulation. Given the successful clearance obtained mechanically, the intraoperative choledochoscopy-guided lithotripsy was not necessary.

To the best of our knowledge, we found no previous description of direct intraductal extraction of an impacted CBD stone using wristed robotic forceps introduced independently through a choledochotomy under simultaneous direct choledochoscopic visualization. We therefore describe this as a choledochoscopy-guided robotic intraductal grasping maneuver and consider it a potentially useful rescue option in selected impacted stones that cannot be captured by conventional basket retrieval. Nevertheless, its safety, reproducibility, and potential advantages over established retrieval or lithotripsy techniques cannot be established from a single case and require further evaluation. Despite the benefits of robotic surgery, the concern of elevated costs remains. Almamar et al. [16] compared robotic and open CBDE, finding no significant difference in operative time but demonstrating lower postoperative complications and shorter hospital stays (6 vs. 12 days). Notably, total hospital costs were lower in the robotic group despite higher procedural expenses, underscoring potential cost-effectiveness in selected complex cases.

CBDSs in patients with surgically altered anatomy, such as after gastrectomy with Billroth I/II reconstruction, esophagectomy with gastric conduit, pancreaticoduodenectomy, hepaticojejunostomy, or Roux-en-Y gastric bypass, represent a significant challenge for endoscopic therapy [6]. While specialized techniques have been developed by experienced endoscopists, they are not universally available, leaving surgery as the only viable option in certain cases. Prior upper abdominal surgery is significantly associated with dense adhesions and distortion of Calot’s triangle. Although minimally invasive CBDE is feasible in such patients, the increased technical difficulty often results in a higher conversion rate to open surgery [17]. In the study conducted by Huang et al. [18], patients with prior upper abdominal surgery undergoing laparoscopic CBDE experienced longer operative times, increased costs, and higher conversion rates. Similarly, Li et al. [19] reported a 17% conversion rate in patients with prior biliary surgery, highlighting the impact of adhesions and distorted anatomy on procedural complexity.

Although the current evidence remains limited and is predominantly based on retrospective series and observational studies, available data suggest that robotic CBDE is technically feasible in selected patients, with encouraging perioperative and stone-clearance outcomes. A recent meta-analysis [20] that included 438 patients who underwent robotic CBDE reported an overall pooled stone clearance rate of 95% and an overall pooled complication rate of 25%. Comparative analysis showed that robotic CBDE was associated with a 34% lower risk of complications compared to open surgery, although open procedures demonstrated a shorter operative time, a difference of 38 min on average. The multicentric study by Stefanova et al. [21], which included 102 patients, revealed that performing robotic CBDE in conjunction with cholecystectomy resulted in a significantly lower conversion rate compared to isolated CBDE in patients with prior biliary surgery (1.4% vs. 30.4%). Further prospective studies are needed to draw definitive conclusions regarding robotic CBDE safety and efficacy compared with other treatments or surgical approaches.

In order to reduce the risk of postoperative bile leakage after choledochotomy in transductal CBDE, intraductal decompression could be considered a valuable strategy, especially in cases where prior sphincterotomy has not been performed [8]. Routine T-tube drainage, once standard, is now largely discouraged due to its association with higher operative times and hospital stay, patient discomfort, dislodgement, infection, electrolyte imbalance, and bile peritonitis [22,23]. Instead, antegrade stent placement has advantages in reducing hospital stay and post-operative complications compared to T-tubes [24,25].

In the present case, a transcystic drain was preferred to reduce intraluminal pressure and minimize the risk of postoperative fistula, as antegrade stent placement was not feasible nor manageable postoperatively due to an endoscopically impassable pyloric stenosis. The drain was maintained closed to prevent electrolyte loss, irrigated daily to preserve patency, and provided both postoperative cholangiographic monitoring and a potential access route for interventional radiology in case of recurrence. No postoperative complications occurred.

The occurrence of stricture after CBDE is uncommon, with a reported incidence ranging between 0% and 0.8% [6]. In the TD approach, preservation of the CBD blood supply is paramount, as ischemic injury from interruption of arteriolar branches is a recognized cause of stricture [26]. Choledochotomy can be performed either longitudinally or transversely [27,28]. Paganini et al. [29,30] recommend transverse choledochotomy to reduce the risk of interrupting marginal arterioles, although longitudinal choledochotomy provides greater flexibility for extension in cases of large stones and facilitates choledochoscope insertion [31].

In the present case, a longitudinal choledochotomy was selected because of the markedly dilated CBD, the presence of large and impacted stones measuring up to approximately 20 mm, and the need for adequate access for repeated stone-retrieval maneuvers and choledochoscopy. The approximately 30-mm longitudinal incision also permitted controlled introduction of the 8-mm wristed robotic forceps during the rescue intraductal grasping maneuver without forced dilation of the ductal opening. This technical advantage was balanced against the potential vascular concern associated with a longitudinal incision by maintaining the choledochotomy on the anterior aspect of the CBD and avoiding extension or excessive dissection toward the lateral 3- and 9-o’clock margins, where the longitudinal arterial supply is particularly vulnerable. No randomized evidence currently establishes the superiority of either incision orientation, and the choice should therefore be individualized according to duct diameter, stone characteristics, required intraductal maneuvers, and local anatomy.

Although the two-month follow-up confirmed ductal clearance and an uncomplicated early postoperative outcome, this interval is insufficient to assess late biliary complications, particularly post-choledochotomy stricture and recurrent choledocholithiasis. Longer clinical and imaging follow-up is therefore required to evaluate the durability of the ductal patency and stone clearance.

Robotic CBDE should ideally be performed in high-volume centers by surgeons experienced in minimally invasive and hepatobiliary surgery, with comprehensive knowledge of biliary anatomy, proficiency in intraoperative cholangiography and IOUS, advanced intracorporeal suturing skills, and expertise in various stone extraction techniques, including the Chopstick method, balloon and Dormia basket retrieval, and choledochoscopy-assisted removal [5,6,7,8].