70: Robotic Excision of a Type I Choledochal Cyst with Roux-en-y Hepaticojejunostomy

Saturday, March 12, 2022

11:01 AM – 11:09 AM CST

Location: Chantilly East

Abstract Presenter(s)

Joanna T. Swinarska, MD

General Surgery Resident
Milton S. Hershey Medical Center
Hershey, Pennsylvania, United States

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Participants should be aware of the following financial/non-financial relationships:

Joanna T. Swinarska, MD: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Introduction: Choledochal cysts are associated with risk of biliary tract malignancy. For Todani type I cysts, which are fusiform dilation of the extraheptic ducts, bile duct resection with hepaticojejunostomy is the preferred treatment. Although these operations are commonly performed in open fashion, these patients are typically young and fairly healthy and would likely benefit from a minimally invasive approach for this prophylactic operation. A robotic-assisted technique is demonstrated in the accompanying video, and makes use of the wristed instruments to assist with dissection and complex reconstruction.

Methods:

The patient originally presented with biliary colic to an outside hospital and underwent ultrasound and MRI which demonstrated a 2.2 cm gallstone and fusiform common bile duct dilation to 1.6 cm without choledocholithiasis. She underwent initial cholecystectomy and was referred to our center postoperatively. CEA was elevated at 8.3 ng/mL (normal < 4.8 ng/mL) and CA 19-9 was < 0.6 units/mL (normal < 36 units/mL). Extrahepatic bile duct resection with Roux-en-Y hepaticojejunostomy (HJ) was recommended using a robotic approach.

The Da Vinci Xi robotic system was used. We began by dissecting out the porta hepatis, using intraoperative indocyanine green (ICG) to help identify the bile duct. The distal common bile duct was mobilized from the head of the pancreas, and divided with a vascular staple load. The proximal common hepatic duct was dissected to the level of the confluence and divided sharply. Frozen sections of the margins were negative for dysplasia or carcinoma. A retrocolic Roux-en-Y HJ was performed using 3-0 PDS in running fashion.

Results:

The patient recovered uneventfully and was discharged on POD 3. At her 2-week follow-up, she had minimal abdominal pain and was returning to her regular daily activities. Final pathology demonstrated no evidence of carcinoma.

Conclusions: This video highlights a technique for robotic excision of a type I choledochal cyst. The minimally invasive approach can expedite post-operative recovery for the patient, while the dexterity of the robot facilitates the creation of the hepaticojejunostomy.

Learning Objectives:

Describe the indications for surgery in a type I choledochal cyst.
Describe the port placement for a robotic excision of a type I choledochal cyst.
Describe the reconstruction technique in a robotic excision of a type I choledochal cyst.