Robotic-Assisted Excision of Type I Choledochal Cyst with Hepaticoduodenostomy

Maitham A Moslim, MD, Matthew Davis, MD, Gareth Morris-Stiff, MD, Federico G Seifarth, MD. Cleveland Clinic Foundation

Case Presentation:  A 15-year-old female with morbid obesity who underwent workup for recurrent right upper quadrant abdominal pain. Ultrasonography detected extra-hepatic cystic lesion. Subsequent Magnetic Resonance cholangiopancreatography demonstrated 3.7 x 3.0 cm type I choledochal cyst. She underwent robotic-assisted excision of choledochal cyst with hepaticoduodenostomy.

Technique details:

  • Extensive adhesions between omentum and the gallbladder were noticed and divided with the hook electrocautery.
  • The gallbladder infundibulum and cystic duct were followed to the choledochal cyst.
  • The cystic duct was clipped and divided with robotic endo-shears.
  • By appropriate retraction and meticulous dissection, the cyst was circumferentially dissected from adhesions to duodenum and surrounding soft tissues.
  • The cyst was periodically decompressed during the procedure by removal and replacement of the cystic duct clip.
  • Distally, the cyst was abutting the portal vein. Careful dissection was performed.
  • A circumferential umbilical tape was placed to hold retraction.
  • The cyst was dissected distally until a sharp tapering to approximately 2-3 mm was noticed adjacent to the pancreatic head.
  • The common bile duct was ligated with 3-0 PDS and 3-0 Vicryl sutures, and then divided after placing a proximal clip.
  • By traction on the cystic duct stump and manipulation of the distal portion of the cyst, it was dissected completely from the proximal portal vein towards the porta hepatis.
  • The first and proximal second portions of the duodenum were mobilized.
  • The cyst was then divided a half centimeter distally from the confluence of the right and left hepatic ducts.
  • A 1 cm duodenotomy was created 5 cm distally to the pylorus in anti-mesenteric longitudinal fashion.
  • A hand-sewn, interrupted hepaticoduodenostomy was performed with 3-0 Vicryl sutures using 4 stitches for the posterior wall and 6 stitches for the anterior wall.
  • Then the cholecystectomy was completed.
  • At the end of the procedure, a drain was placed at the anastomotic site.

Post-operative Course: 

  • Patient tolerated the procedure well and was transferred to regular nursing floor for recovery.
  • NG tube was removed on postoperative day 3. Diet was advanced as tolerated with return of bowel functions.
  • She was discharged on postoperative day 5 after removal of the drain.
  • She was doing well 5 weeks following the surgery.
  • Pathology showed type I choledochal cyst with no dysplasia.

Conclusion:  Here in we present a unique case of robotic-assisted excision of choledochal cyst with hepaticoduodenostomy.

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