Lessons and Tips from the Experience of Pediatric Robotic Choledochal Cyst Resection

Purpose: The laparoscopic surgery for a choledochal cyst in children is technically challenging because of its high degree of complexity despite its possibility. In an attempt to overcome this laparoscopic weakness and to facilitate the difficult steps in the minimally invasive surgery for choledochal cyst resection in children, we have performed the robot-assisted resection of the choledochal cyst. The aim of this study is to report lessons and tips obtained from our experience of the robot-assisted choledochal cyst resection in children. Patients and Methods: From July 2008 to October 2011, we have attempted robot-assisted resections of choledochal cyst for 14 children using the da Vinci Robotic Surgical System (R) (Intuitive Surgical, Sunnyvale, CA). We analyzed retrospectively reviewed medical records for patients' clinical characteristics, operative methods, and postoperative outcomes including operative time, hospital days, and complications. Results: In 3 early consecutive cases, we encountered serious technical problems and complications. However, after the operator underwent the robot system off-site training program, complete resection of the choledochal cyst and Roux-en-Y hepaticojejunostomy were performed successfully without difficulty and any complication in the 11 later consecutive cases. The important technical developments of our late-period operations include placing the patient's body above the operative table, performing the extracorporeal jejunojejunostomy through an umbilical incision, omitting the operative cholangiography with magnetic resonance cholangiopancreatography substitution, exposure of the porta hepatis by lateral retractions of the gallbladder and the falciform ligament with anchoring sutures to the abdominal wall, and using a third robotic arm for counter-traction of tissues for careful dissection. Conclusion: We believe that the techniques of pediatric robotic choledochal cyst resection have evolved from the previous experiences to be safer and easier.