Robotic Excision of Choledochal Cyst with Hepaticoduodenostomy (HD): Report of HD Technique, Initial Experience, and Early Outcome.

INTRODUCTION:  Minimal access surgical approach to choledochal cyst (CC) is becoming a standard of care in pediatric age group. Robotic-assisted excision of CC is increasingly being practiced at centers which have access to the system. We present our experience and technique of hepaticoduodenostomy (HD). Over all initial experience, short-term outcomes and complications are also presented and discussed.

MATERIALS AND METHODS:  Patients with CC and undergoing robotic excision were retrospectively studied. Patients with active cholangitis, liver dysfunction, and perforated CC were excluded for robotic procedures. All included patients were preoperatively evaluated as per the defined protocol. They underwent excision of CC with HD. The duodenal anastomosis was done after limited mobilization and emphasis was laid on anastomosing the distal D2 part to the common hepatic duct. This prevents bile reflux into stomach. The follow-up evaluation was done for these patients. Hepatobiliary iminodiacetic acid (HIDA) scan for duodenogastric reflux (DGR) was done only if patients reported symptoms related to it.

RESULTS:  A total of 19 patients (10 females) were studied. The mean age was 84 months. Type 1b was present in 12 patients and the rest were type IVb. Complete cyst excision with HD was done in all patients except conversion to open in one patient. The mean surgical time was 170 ± 40 minutes with console time of 140 ± 20 minutes. Median follow-up duration is 2.5 years (range: 3.5-0.5 years). HIDA scan was done in five patients who had reported epigastric pain. Of these five, one patient had a positive DGR. He is on conservative management.

CONCLUSION:  Robot-assisted CC excision with HD is feasible as proven by the outcome of 19 patients presented in this series. HD is to be done away from pylorus in distal part of down curving D2. This particular step prevents DGR and is the most important point of technique in doing HD. The presented series is the first report of robotic excision of CC with HD. The robot is a facilitator for complex and difficult operations as CC excision and HD.