Robot-assisted hepatectomy and complete excision of the extrahepatic bile duct for type IV-A choledochal cysts

Ji Wool Ko, MD1, Sung Hoon Choi, MD1, Sung Won Kwon, MD, PhD1, Kwang Hyun Ko, MD, PhD2. 1Department of Surgery, CHA Bundang Medical Center, CHA University, 2Department of Internal Medicine, CHA Bundang Medical Center, CHA University

Background: Complete removal of the dilatated biliary tree is regarded as inevitable in choledochal cysts due to its malignant potential. However, technical difficulty and the high risk of postoperative complications as well as the various presentations of the disease make the surgical options for type IV-A cysts challenging and controversial. We report the first case of a type IV-A choledochal cyst treated using a robot-assisted approach.

Patient and Methods: A 41-year-old healthy female was admitted with intrahepatic and extrahepatic cysts incidentally found on routine check-up. Preoperative image studies showed two large cystic dilatations of the main biliary tract at the hilum and distal common bile duct as well as multiple cystic dilatations of the left intrahepatic duct. Anomalous pancreatico-biliary duct union (APBDU) was also found. A transumbilical camera port and three 8-mm working trocars with one 12-mm assistant’s trocar were docked in a 30-degree reverse-Trendelenburg position. The mid common bile duct was transected first, and the distal cystic bile duct of the intrapancreatic portion was resected at the junction with the pancreatic duct. Then, left hepatectomy with caudate lobectomy was performed to remove the hilar cyst and to isolate the right hepatic ducts. The right anterior and posterior hepatic ducts were securely isolated and resected with the help of real-time fluorescent imaging using an ICG. The two openings of the intrahepatic ducts were prepared as a single opening, and Roux-en-Y hepaticojejunostomy was performed intracorporeally. The specimen was retrieved through Pfannenstiel skin incision.

Result: The total operation time was 540 minutes. The estimated amount of intraoperative bleeding was 300 ml. No blood transfusion was given. CT on postoperative day 6 showed no complications, such as the patency of biliary tract and pancreatic leakage. Pathologic examination was accorded in choledochal cysts without evidence of malignancy. The patient was discharged on postoperative day 7 in good condition and followed up for 8 months without complication.

Conclusion: Hepatectomy and complete excision of the extrahepatic bile duct for type IV-A choledochal cysts requires fine and delicate surgical techniques. The wrist-like movement of the working instruments and the firefly imaging of the robot surgical system allowed this advanced minimally invasive surgery to be successfully performed on this patient.

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