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.
- 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.
- 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.