IPEG 2020 Top Abstract: Robotic excision of type IV choledochal cyst with hepaticoduodenostomy

This is an 8-year-old girl who presented with a history of right upper quadrant pain and a 12 pound weight loss over 4 months. Ultrasound of the right upper quadrant was obtained, which showed fusiform dilation of the common bile duct, measuring up to 2 centimeters at the mid portion, as well as intrahepatic ductal dilation up to 10 millimeters. MRCP was then obtained, which showed a 2.2 centimeter common bile duct with distal narrowing at the pancreatic head and dilated intrahepatic ducts, consistent with a type 4 choloidocal cyst. The decision was made to proceed with robotic assisted choloidocal cyst resection with hepatico duodenostomy. After a safe entry into the abdomen, an attempt was made to identify biliary structures and dissect the cyst free. Discerning the cyst from the gallbladder was difficult, so the cystic duct and artery were dissected free from peritoneal attachments, and the gallbladder was used as a handle to retract the liver. The cyst was dissected free from the portal vein and hepatic artery, and a Penrose drain was placed around the cyst and used to provide further traction. The cyst was dissected down to the pancreatic bed. It was clipped and divided as distally as possible on the pancreatic bed. Dissection was then carried up to the hepatic ducts as proximately as possible so that the cyst was divided at the confluence of the hepatic ducts about 1 centimeter away from liver parenchyma. 3 hepatic ducts were identified. The duodenum was next partially cacherized so that it reached to the hepatic ducts, and a 2.5 centimeter longitudinal duodenotomy was made. The hepatico duodenostomy was made using 25 interrupted 30 viral sutures. The articulating robotic needle drivers are especially helpful with this task, and the anastomosis was fashioned from posterior to anterior under no tension. Shown is the completed hepatico duodenostomy. The choloidocal cyst was then dissected free with the remainder of the gallbladder. A drain was placed in the hepatic space prior to closure. Postoperatively, the patient had no complications. She was advanced to a general diet by postoperative day 3. Her drain was pulled on postoperative day 4, and she was discharged home. On follow-up visits at 1 in 6 months, she was having no further issues with weight gain or abdominal pain. The decision to perform hepaticoduodenostomy to reconstruct the biliary tree is well supported in the literature, although sores at all support Ruin Y hepatico jejunostomy as the preferred method for reconstruction due to decreased bile reflux and lower incidence of cholangitis. A meta-analysis comparing hepaticoduodenostomy to hepatico jejunostomy conducted by Narayan et al. showed no significant difference in incidence of cholangitis between hepaticoduodenostomy and hepaticojejunostomy reconstruction, and ultimately conclude that hepaticoduodenostomy is comparable to hepaticojejunostomy in terms of overall complication rate. Additionally, Limb suggests that hepatico duodenostomy is the preferred procedure due to decreased fat malabsorption, shorter operating time, and no difference in postoperative biliary leak. Silva Bayazidal concur and state that hepatico duodenostomy is a safe operation to perform with few postoperative complications. We have demonstrated a case of robot-assisted hepaticoduodenostomy reconstruction for type 4 choloidocal cyst as a method for effective management of this pathology.