Robotic Resection of Choledochal Cyst, Portal Lymph Node Dissection, and Roux-En-Y Hepaticojejunostomy

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Background: A 33-year-old female presented with acutely-worsening right upper quadrant pain of several months duration. Ultrasound demonstrated a focal common bile duct dilation with choledocholithiasis. Blood chemistries and tumor markers were normal. MRCP showed a fusiform dilation, believed to be a Type I choledochal cyst, measuring 2.6 x 1.5 cm. Over 80% of choledochal cysts are diagnosed within the first decade of life, and surgical removal is the standard of care. In the adult, the risk of malignant transformation is 10 to 30%, with Type I and IV cysts having the highest rates.

Methods: Using the Da Vinci Xi Surgical System, the patient underwent resection of choledochal cyst, portal lymph node dissection, and roux-en-y hepaticojejunostomy. There were no intraoperative complications.

Results: The total operative time was 3 hours and 54 minutes; total robotic time was 3 hours and 27 minutes. The specimen was completely excised with adequate margins on frozen and final pathology. Recovery was without incident or complication.

Conclusion: In our experience, a robotic assisted approach provides better anatomic visualization and increased dexterity for suturing the hepaticojejunostomy anastomosis, when compared to laparoscopy. Minimally-invasive excision is a safe alternative to open excision; this approach offers decreased post-operative pain and ileus, shorter hospital stay, and improved cosmesis.