Robotic-assisted excision of a type Ib choledochal cyst with Roux-en-Y hepaticojejunostomy in an adult with a 4-mm hepatic duct: A technical perspective

Choledochal cysts are rare congenital dilatations of the biliary tree and are increasingly diagnosed in adults due to widespread use of cross-sectional imaging. Complete cyst excision with Roux-en-Y hepaticojejunostomy (RYHJ) is the standard of care to prevent long-term complications such as cholangitis and malignant transformation. Biliary reconstruction in the presence of a narrow hepatic duct remains technically challenging and is associated with a higher risk of postoperative bile leak. This video article describes a stepwise robotic technique for cyst excision and precise biliary reconstruction in an adult patient with a 4-mm common hepatic duct. A 40-year-old woman presented with recurrent right upper abdominal pain and was diagnosed on magnetic resonance cholangiopancreatography with a 3-cm saccular dilatation of the mid-common bile duct consistent with a Todani type Ib choledochal cyst. She underwent elective robotic-assisted cyst excision and RYHJ using the da Vinci Xi system. Key technical steps included standardized port placement for optimal hilar exposure, use of indocyanine green fluorescence imaging to delineate biliary anatomy, circumferential cyst dissection and transection at healthy ductal margins. A tension-free duct-to-mucosa hepaticojejunostomy was fashioned using interrupted fine absorbable sutures. The procedure was completed with minimal blood loss and no intraoperative complications. The postoperative course was uneventful, with no bile leak or infective complications, and the patient was discharged on postoperative day three. Robotic-assisted excision with RYHJ enables precise dissection and secure biliary reconstruction, even in the presence of a narrow hepatic duct, when meticulous technique is applied.