Robotic-Assisted Excision of a Type I Choledochal Cyst with Hepaticoduodenostomy and Intraoperative Identification of Gallbladder Agenesis

Abstract

Introduction:

Choledochal cysts are rare congenital anomalies of the biliary tract, most often diagnosed in children. ¹ Historical management involves open cyst excision with biliary-enteric reconstruction, though minimally invasive techniques remain technically challenging due to the complexity of the anastomosis. ¹ Robotic-assisted surgery offers enhanced dexterity and visualization compared with laparoscopy and has gained momentum internationally. ¹ Gallbladder agenesis is another rare anomaly, occurring in 10–60 per 100,000 individuals. ^{2 –4} The coexistence of gallbladder agenesis and choledochal cyst is exceptionally uncommon, with only a few reported cases, including just one in a pediatric patient. ^{2 –4} We present the first pediatric case of a type I choledochal cyst with gallbladder agenesis, successfully managed with robotic-assisted excision and hepaticoduodenostomy.

Materials and Methods:

A 6-year-old female presented with recurrent abdominal pain, nausea, and vomiting. Imaging revealed a fusiform dilation of the common bile duct consistent with a Todani type I choledochal cyst. A robotic-assisted resection with biliary reconstruction was planned. Intraoperative exploration confirmed gallbladder agenesis. Because the gallbladder and cystic duct are typically used for traction and anatomical orientation, liver retraction was achieved with the robotic arm, and the cyst itself was grasped for counter-traction. The cyst was mobilized and excised with the assistance of indocyanine green fluorescence. The choledochal cyst was dissected distally to the level of the duodenum, where tapering was noted, and divided using a vascular stapler based on surgeon preference. Biliary continuity was restored via an intracorporeal hepaticoduodenostomy in the second portion of the duodenum (D2). The surgical procedure is presented in stepwise fashion with narration.

Results:

The procedure lasted 192 minutes and was completed without complication. A drain was placed and removed prior to discharge. The patient tolerated diet advancement by postoperative day 3 and was discharged home on postoperative day 5. At 2-week follow-up, she was asymptomatic with full resolution of symptoms. At 3 months, ultrasound confirmed normal biliary anatomy without dilation or complication. While this represents a single patient case, robotic resection has been reported in small pediatric series. ¹ This case contributes to the limited global experience and represents the first pediatric report of gallbladder agenesis with a type I choledochal cyst treated robotically.

Conclusions:

Robotic-assisted resection with hepaticoduodenostomy is a feasible and safe option for complex congenital biliary anomalies. This case highlights both the diagnostic challenges of gallbladder agenesis and the technical advantages of robotic biliary reconstruction. Robotic platforms expand minimally invasive options for complex hepatobiliary surgery in children. Close long-term surveillance is warranted, as patients with choledochal cysts remain at lifelong risk for biliary malignancy and should undergo at least annual follow-up. ¹

Patient consent statement:

Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure.

Source of work and conflicts of interest:

This work was performed at Corewell Health William Beaumont University Hospital. The authors report no conflicts of interest or obligations related to this work.

Author disclosure statement:

The authors declare no commercial associations or financial relationships within the past 3 years that could be viewed as potential conflicts of interest in connection with this submission.

Runtime of video:

6 mins 58 secs.