Robotic excision of adult choledochal cyst with total intra-corporeal reconstruction
Complete excision with a Roux-en-Y hepatico-jejunostomy reconstruction is the standard treatment for type 1 choledochal cysts.1 With the advancement of laparoscopic and robotic skills, an increasing number of reports on performing this complex operation by minimal access surgery has been noted.2,3 However, its development is limited by the technical complexities of the procedures and the rigid nature of the instruments. The robotic surgical system might help to overcome these obstacles, and its use has been reported, but mainly in paediatric patients, where reconstruction is mostly extra-corporeal.4 Only one adult case had been reported, and reconstruction was performed extra-corporeally.5 In the present study, we report our experience of robotic excision of a type 1 choledochal cyst with total intra-corporeal reconstruction in a young adult.
A 28-year-old man presented with recurrent epigastric pain with normal blood tests and upper endoscopy results. Further evaluation with ultrasonography of the abdomen, computed tomography scan and magnetic resonance cholangiopancreatography revealed a fusiform dilatation of common bile duct (CBD). He underwent robotic excision of the choledochal cyst and total intra-corporeal reconstruction with hepatico-jejunostomy and jejuno-jejunostomy in a Roux-en-Y manner.
After a full diagnostic laparoscopy, the liver was retracted with the third robotic arm. The gallbladder was first dissected with a fundus-first approach. Dissection around the choledochal cyst continued inferiorly to the pancreas until tapering of the lower end of the CBD, which was then suture ligated and divided. The choledochal cyst was then reflected proximally. The common hepatic duct (CHD) was dissected free until a normal caliber CHD was noted. The right hepatic artery was identified and protected. Transection of the CHD was performed with diathermy, and the specimen was put into a plastic bag. Reconstruction was performed first by identifying the proximal jejunum, which was transected by an Endo GIA stapler (Covidien, Norwalk, CT, USA). Side-to-side jejuno-jejunostomy was created with the Endo GIA at approximately 40 cm distal to the estimated hepatico-jejunostomy site. The enterostomy site for stapler application was closed with a single-layer continuous 3/0 vicryl suture. An end-to-side ante-colic hepatico-jejunostomy was fashioned with single-layer interrupted 3/0 vicryl sutures. A silicone drain was placed to the right sub-hepatic space after haemostasis was ascertained and no bile leak was noted. The specimen was retrieved through the sub-umbilical wound without extension.
The total operation time was 568 min. No intra-operative complication was encountered. The total blood loss was 280 mL. The patient had an uneventful post-operative recovery and was discharged on post-operative day 5. No re-admission was required, and there was no recurrent cholangitis following the operation.
Robotic excision of choledochal cysts is safe and feasible. It should be an ideal case to start with in the initial phase of performing robotic approach hepatico-biliary surgery, as it requires a lot of dissection and suturing skills for the two anastomoses. The specimen is small, and an extension of the wound is not necessary if the reconstruction could be done intra-corporeally. Moreover, it is a benign disease, and therefore, oncological clearance is not a problem. As a result, the advantages of the robotic system can be fully manifested.
Additional video images may be found in the online version of this article.