Robot-assisted Cyst Excision, Ductoplasty, and Embedding Portoenterostomy for Choledochal Cysts with a Small Caliber Hepatic Duct less than 6 mm

Anastomotic stricture is a primary concern following the surgical treatment of choledochal cysts (CC), particularly in pediatric patients with narrow bile ducts (<6 mm), and remains the main indication for re-operation. Robotic-assisted surgery (RAS), with its superior 3D visualization and instrument dexterity, offers an ideal platform for the complex reconstruction required to prevent this complication. This study presents a robot-assisted modified technique designed to mitigate the risk of stricture, as demonstrated in a 34-month-old female with a Type Ia CC. The procedure involves complete cyst excision followed by ductoplasty and an embedding portoenterostomy to create a broad anastomosis. During a median follow-up of 34 months in a cohort of 28 patients, no abnormal liver function tests, intrahepatic stones, cholangitis, or anastomotic strictures were observed. This technique creates a broad, tension-free portoenterostomy by shifting the scar line away from the lumen, providing an effective solution for treating CC patients with a small-caliber hepatic duct.