Robotic-assisted transduodenal marsupialization of a choledochocele causing recurrent pancreatitis in an adolescent with pancreas divisum: a case report

Acute recurrent pancreatitis in children is uncommon, and identifying structural etiologies is critical to definitive management, including evaluation for rare etiologies such as pancreas divisum and choledochoceles. A previously healthy 17-year-old male presented with a prolonged course of episodic abdominal pain and several admissions for recurrent pancreatitis. During his workup, he was found to have elevated serum lipase and amylase, consistent with pancreatitis. Magnetic resonance cholangiopancreatography (MRCP) demonstrated pancreas divisum and a 1-cm type III choledochocele at the duodenal ampulla, forming an anomalous common channel between the distal bile and ventral pancreatic ducts. Secretin-enhanced MRCP and subsequent percutaneous transhepatic cholangiography via the gallbladder confirmed ventral duct obstruction and reflux of highly amylase-rich pancreatic secretions into the biliary system. Given these findings, the patient underwent robotic-assisted transduodenal excision and marsupialization of the choledochocele with concurrent cholecystectomy. Intra-operatively, gallbladder fluid was aspirated for biochemical analysis and a complete Kocher maneuver was performed, allowing for adequate exposure and a longitudinal duodenotomy along the medial aspect of the distal second portion of the duodenum to identify the choledochocele. SPY-PHI ICG fluorescence was used for both identification of the choledochocele and confirmation of separation of the two ductal lumens. The operation was completed without complications. Postoperative recovery was notable for minimal pain, discharge on postoperative day one, and complete resolution of symptoms without recurrent pancreatitis at three-, six-, and twelve-month follow-up. Robotic-assisted transduodenal marsupialization appears to be a feasible and effective approach for the management of choledochocele.