j o u r n a l o f s u r g i c a l r e s e a r c h
n o v e m b e r 2 0 2 3 ( 2 9 1 ) 4 7 3 e4 7 9

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journal homepage: www.JournalofSurgicalResearch.com

Society of Asian Academic Surgeons

Robotic Surgery for Pediatric Choledochal Cysts:

An American Case Series and Literature Review

Scott H. Nguyen, MD,a,* Maveric Abella, BS,b Joseph V. Gutierrez, MD,a

Benjamin Tabak, MD,a Devin Puapong, MD,b Sidney Johnson, MD,b
and Russell K. Woo, MDb
a
Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii
b
John A Burns School of Medicine, Honolulu, Hawaii

article info abstract

Article history: Introduction: Choledochal cysts are rare congenital biliary cystic dilations. The US incidence
Received 2 December 2022 rate varies between 5 and 15 cases per 1,000,000 people. In contrast, Asians, which are a
Received in revised form large subset of the population of Hawaii, have an incidence of approximately one in every
1 June 2023 1000 births. We report our experience with robot-assisted laparoscopic surgical manage-
Accepted 25 June 2023 ment with biliary reconstruction of choledochal cysts which to date is the largest American
Available online 31 July 2023 case series to be reported.
Materials and Methods: From 2006 to 2021, patients diagnosed with a choledochal cyst(s) at a
Keywords: tertiary children’s hospital were retrospectively reviewed. Perioperative analysis was per-
Cholangitis formed. Complications were defined as immediate, early, or late. The data underwent
Choledochal cysts simple descriptive statistics.
Hepaticoduodenostomy Results: Nineteen patients underwent choledochal cystectomy and hepaticoduodenostomy.
Jaundice Thirteen underwent a robotic approach while the rest were planned laparoscopic. Eighteen
Robot-assisted laparoscopy of 19 were female with 15/19 of Asian descent. The ages ranged from 5 mo to 21 y. Pre-
senting diagnoses included jaundice, primary abdominal pain, pancreatitis, and chol-
angitis. Sixty eight percent had type 1 fusiform cysts while the rest were type 4a. Operative
time and length of stay for robotic versus laparoscopic were 321 versus 267 min and 8.2
versus 17.3 d, respectively. For the robotic group, there was one immediate complication
due to peritonitis. One-year follow-up revealed two patients requiring endoscopic retro-
grade cholangiopancreatography with dilation/stenting for an anastomotic stricture. There
were no anastomotic leaks.
Conclusions: Robot-assisted laparoscopic choledochal cystectomy with hep-
aticoduodenostomy is associated with overall good outcomes with the most common long-
term complication being anastomotic stenosis.
Published by Elsevier Inc.

* Corresponding author. General Surgery Resident Physician, Division of Surgery, General Surgery, Tripler Army Medical Center, 1 Jarrett
White Road, Medical Center, Honolulu, HI 96859.
E-mail address: scott.ho.nguyen@gmail.com (S.H. Nguyen).
0022-4804/$ e see front matter Published by Elsevier Inc.
https://doi.org/10.1016/j.jss.2023.06.034
474 j o u r n a l o f s u r g i c a l r e s e a r c h
n o v e m b e r 2 0 2 3 ( 2 9 1 ) 4 7 3 e4 7 9

Introduction index, etc.), intraoperative variables (operative time, anes-

thesia time, type of cyst, etc.), and postoperative variables
Choledochal cysts are a rare benign congenital abnormality (length of stay [LOS], any complications, etc.). Patients were
characterized by cystic dilation of the biliary tree. The inci- divided into laparoscopic and robot-assisted cohorts to allow
dence rate among the general US population varies between for descriptive comparison. Operative time was defined as
about 5 and 15 cases per 1,000,000 people.1 However, the inci- from “skin incision” to “skin closure” as designated in the
dence rate among Asians, who make up a large subset of the electronic medical record. Complications were defined as
state of Hawaii’s population, is significantly larger, consisting of immediate (same-hospital stay), early (within 30 days after
approximately one in every 1000 births.2 Newborns with chol- discharge), or late (after 30 days). The data underwent simple
edochal cysts can be identified antenatally or based on pre- descriptive statistics.
sentation (abdominal pain, prolonged neonatal jaundice, In brief, the steps of the robot operation are as follows
pancreatitis, or cholangitis). Diagnosis is typically performed (same for da Vinci Si and Xi Surgical System) (Figs. 1 and 2).
with abdominal ultrasound followed by advanced imaging
such as magnetic resonance cholangiopancreatography. 1. Diagnostic laparoscopy to confirm diagnosis and anatomy
Currently, the preferred treatment is complete cyst exci- 2. Cholecystectomy via a top-down approach
sion and if indicated, biliary-enteric reconstruction with sur- 3. Circumferential dissection of the cystic common bile duct
gical options to include either hepaticoduodenostomy or 4. Ligation of the distal common bile duct (extra-pancreatic)
hepaticojejunostomy. If left untreated, the child may develop 5. Sharply transect the proximal common bile duct at the
cholangitis, pancreatitis, cirrhosis, portal hypertension, or level of the hepatic bifurcation
malignant transformation to cholangiocarcinoma in the 6. Kocher maneuver
future. With the introduction of robotic-assisted laparoscopy 7. Duodenotomy along second portion of the duodenum
into the minimally invasive surgical world, the shift from 8. Primary interrupted hepaticoduodenostomy
conventional laparoscopic to robot-assisted laparoscopic 9. Cyst removal via umbilicus
surgery has grown in popularity.3 This is due to the robot’s
stereoscopic visualization, enhanced dexterity, tremor
reduction, and additional degrees of freedom via wristed in-
struments. These features can facilitate the most difficult Results
portion of the operation which is the creation of the hepatico-
enteric anastomosis.4 Here, we report our experience and Nineteen patients were identified who underwent chol-
outcomes with robot-assisted laparoscopic surgical manage- edochal cystectomy with a hepaticoduodenostomy recon-
ment of choledochal cysts, including a descriptive comparison struction from 2006 to 2021 with a 12-month follow-up period.
to a historical cohort of laparoscopic only procedures. To our All but one of the patients was female. Fifteen of 19 patients
knowledge, this represents the largest American case series were of Asian or Native Hawaiian descent. The ages ranged
reported to date. from 5 mo to 21 y. Fifteen of the 19 patients presented with
symptoms of abdominal pain, while four presented with
jaundice and a total bilirubin ranging from 7.4 to 8.7 mg/dL.
Materials and Methods Seven patients presented with pancreatitis. Only two patients
presented with cholangitis.
From 2006 to 2021, all patients who were diagnosed with a
choledochal cyst (s) at Kapi’olani Medical Center for Women
and Children in Honolulu, Hawaii were retrospectively
reviewed. A regulatory review was performed by the Hawaii
Pacific Health Research Institute and approval for waiver of
informed consent was obtained. Inclusion criteria include all
patients diagnosed with choledochal cysts who underwent
choledochal cystectomy with biliary reconstruction. Exclusion
criteria included any patient who received a concurrent sur-
gical procedure not addressing the patient’s choledochal cyst.
There were three practicing board-certified pediatric surgeons
operating at this tertiary children’s hospital during this time
frame. The robotic platform used was the da Vinci Surgical
System (Intuitive SurgicaleSunnyvale, California). The model
originally used was the da Vinci Si Surgical System which was
transitioned to the Xi model in October 2019. The medical
charts were examined by the authors, the data deidentified,
and analyzed using Microsoft Excel (Microsoft Corporation,
Redmond, Washington). A retrospective analysis of electronic
medical records was performed of variables including de-
mographic characteristics (age, sex, weight, height, body mass Fig. 1 e Patient and equipment positioning.
 nguyen et al
robotic peds surgery choledochal cysts 475

Patient “Q” underwent surgery 165 days after diagnosis due to

Fig. 2 e Robotic port placement.
Specifically, 13 of the 19 patients underwent robot-assisted
laparoscopic choledochal cystectomy with a hep-
aticoduodenostomy reconstruction from 2013 to 2021. Eleven
of the 13 patients underwent the procedure with the da Vinci
Si Surgical System, while the two most recent were completed
with the Xi model (Tables 2 and 3). All these patients were
female. Ten of the 13 patients were of Asian or Native Ha-
waiian descent. The ages ranged from 14 mo to 21 y. The
median age was 6 years with an interquartile range (IQR) of 25-
144 months. The patient’s weights ranged from 7.3 kg to 84 kg.
All the patients underwent ultrasonography and/or mag-
netic resonance imaging to diagnose choledochal cysts as the
patient’s primary pathology. Based on the Todani choledochal
cyst classification, 13 patients had a type 1 choledochal cyst
while the rest were type 4a. The time from diagnosis to sur-
gery was approximately 42 days. Of note, there were two
outliers. Patient “A” underwent surgery 12 months after
diagnosis. The pathology was noted via magnetic resonance
imaging on the island of Kauai, Hawaii, and the patient was
sent to an outside hospital for an endoscopic retrograde
cholangiopancreatography (ERCP) procedure. The mother
declined a surgical intervention at the time of diagnosis until
the patient developed recurrent symptoms a year later.
the patient being pregnant and delivering her child first prior
to addressing her choledochal cyst.
The overall mean operative time was 331  120 min or
approximately 5.5 h. The median operative time was 349 min
(IQR 268-373). The overall average LOS was 11.1  9.2 days. The
median LOS was 8.4 days (IQR 4-17.8). For the robotic pro-
cedures, the operative time was 321  84 min or approxi-
mately 5.5 h with a total LOS of 8.2  7.5 days. Median
operative time and LOS for robotic procedures were 304 min
(IQR 269.5-360) and 4.4 days (IQR 3.4-14.8), respectively. When
comparing the Si and Xi models, the operative time and total
LOS were 308.5 versus 392 min and 8.9 versus 4 days, respec-
tively. Six patients underwent a planned laparoscopic
approach from 2006 to 2012 (Table 1). The operative time for
this group was 366  216 min or approximately 7 h with a total
LOS of 17.3  10.3 days. However, two of the six patients did
not have operative times listed. One of the six laparoscopic
cases was converted to open. Patient “C” converted to open
due to significant scaring (from multiple episodes of chol-
angitis) precluding a safe laparoscopic approach. Once those
outliers were removed, the mean operative time for laparo-
scopic group was 267  104 min.
There were two patients who had an immediate compli-
cation within the same admission (reoperation).Patient “F”
from the laparoscopy group experienced postoperative
bleeding. On postoperative day #2, the patient developed
bleeding from his/her surgical site and proceeded rapidly into
hemorrhagic shock with upper gastrointestinal bleeding and
retroperitoneal bleeding. The patient was found to have an
INR of 13. The patient was given vitamin K intravenous 
3 days, 3 units of fresh frozen plasma, and 1 unit of packed red
blood cell. Hematology was consulted, and the final diagnosis
was an underlying undiagnosed vitamin K deficiency with
resulting severe coagulopathy prompted by the stress of the
recent surgery. The patient did not need a reoperation. Patient
“P” from the robotic group was taken to the operating room
with concerns for an anastomotic leak in the setting of peri-
tonitis on physical examination on postoperative day #3.

Table 1 e Laparoscopic cases.

Patient A B C* D E F Summary
Gender F F F M F F 5/6 female
Race Asian Asian NH/PI Asian White NH/PI
Age (mo) 36 192 192 124 120 5 111  77.8
Height (cm) 98 N/A 157.5 132.2 136.3 63.5 117  37.0
Weight (kg) 14.2 53.5 59 21.8 31.8 6.8 31  21.2
Presenting symptom AP AP AP AP AP Jaundice
Type of cyst (Todani) 1 4a 1 1 1 1
Diagnosis to surgery (d) 365 2 8 21 8 13 70  144.9
Operative time (min) N/A N/A 663 492 369 160 421  211.7
Length of stay (d) 9.0 13.0 27.4 31.1 5.1 18.2 17.3  10.3
Postop complication No No No No No Yesy 1/5 (20%)

NH/PI ¼ Native Hawaiian or Pacific Islander; cm ¼ centimeters; kg ¼ kilograms; AP ¼ abdominal pain; postop ¼ postoperative.
*
Laparoscopic converted to open.
y
Bleeding.
476 j o u r n a l o f s u r g i c a l r e s e a r c h
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Table 2 e Robotic Si platform cases.

Patient G H I J K L M N O P Q Summary
Gender F F F F F F F F F F F All female
Race AA Asian NH/PI NH/PI Asian Asian Asian White NH/PI Asian NH/PI -
Age (mo) 72 14 24 16 168 48 25 168 84 72 252 85.7  77.8
Height (cm) 125 69 86 71 155 104 79 150 119 109 159 111  33.3
Weight (kg) 21.7 7.3 10.9 7.3 58.2 15.0 11.4 54.5 21.4 20.5 84.3 28.4  25.5
Presenting symptom AP, E J AP, J AP AP AP, J F, E AP AP I AP -
Type of cyst (Todani) 1 4a 1 4a 1 4a 1 1 1 1 1 -
Diagnosis to surgery (d) 7 8 N/A 10 6 37 15 19 3 7 165 27.7  49.2
Operative time (min) 304 282 174 257 353 373 245 385 349 304 367 308.5  65.2
Length of stay (d) 4.0 4.4 1.2 19.2 3.4 12.3 23.6 8.4 3.4 17.3 1.0 8.9  7.9
Postop complication N Y* N N N N N N Yy N N 2/11 (18%)

NH/PI ¼ Native Hawaiian or Pacific Islander; cm ¼ centimeters; kg ¼ kilograms; AP ¼ abdominal pain; J ¼ jaundice; F ¼ fever; E ¼ emesis; I ¼
incidental; postop ¼ postoperative.
*
Underwent EGD for small bowel bacterial overgrowth as an outpatient.
y
Cholangitis and hepaticoduodenostomy stricture requiring endoscopic stenting.

Intraoperatively, the patient did not have an anastomotic leak.
Instead, serosanguinous fluid was found in the abdomen with
no evidence of active bleeding. A drain was placed, and the
remainder of the patient’s hospital course was uneventful.
Overall, four patients required readmission. Patient “J”
experienced PO intolerance and dehydration which was
treated medically. Two patients experienced cholangitis (pa-
tients “L” and “R”) with both responding to intravenous anti-
biotic therapy only. Patients “H,” “O,” and “R” experienced late
complications necessitating upper endoscopic interventions
(Table 2). Patient “R” developed recurrent cholangitis requiring
ERCP with dilation and stenting of the hepaticoduodenostomy
due to anastomotic stricture. There were 260 days from sur-
gery to ERCP for this patient. Patient “O” experienced
abdominal pain associated with cholestasis but no evidence of
sepsis secondary to an anastomotic stricture that required
ERCP with dilation and stenting 61 days from index surgery to
ERCP. Overall, none of the patients had any other complica-
tions specifically to include anastomotic leaks, surgical site
infection, residual cysts, or death.
Discussion
This case series includes 13 pediatric patients with chol-
edochal cysts who underwent robot-assisted laparoscopic
cyst resection and hepaticoduodenostomy reconstruction
between 2013 and 2021. A second historical cohort of six
laparoscopic cyst resections completed over a similar time
period was included to provide a descriptive comparison of
the experience with the two surgical techniques at our insti-
tution. The 19 patients in this series represent all patients with

Table 3 e Robotic Xi platform cases.

Patient R S Summary
Gender F F All female
Race Asian White -
Age (mo) 144 26 85  83.4
Height (cm) 146 93.5 119.8  37.1
Weight (kg) 40.5 14.9 27.7  18.1
Presenting symptom AP AP, E -
Type of cyst (Todani) 4a 4a -
Diagnosis to surgery (d) 33 5 19  19.8
Operative time (min) 516 268 392  175.4
Total length of stay (d) 4.5 4 4  0.4
Postop complication Y* N 1/2 (50%)

cm ¼ centimeters; kg ¼ kilograms; AP ¼ abdominal pain; E ¼ emesis; postop ¼ postoperative.

*
Cholangitis and hepaticoduodenostomy stricture requiring endoscopic stenting.
 nguyen et al
robotic peds surgery choledochal cysts
choledochal cysts who underwent surgical resection in the
study time period. Although it is unclear why there were more
patients in the robotic cohort, we suspect that the overall low
incidence of the disease with resultant annual variability as
well as the maturation of our hospital’s surgical program
leading to increased patient capture may be contributing
factors.
Of the 13 patients who underwent robot-assisted laparo-
scopic cyst resection and hepaticoduodenostomy recon-
struction, there was a low rate of morbidity and no mortality.
Overall morbidity appears to stem from anastomotic stric-
tures (2/12 or 16.7%) resulting in biliary obstruction with
associated jaundice, abdominal pain, and/or subsequent
cholangitis. All of which were promptly recognized and
treated appropriately with ERCP, anastomotic dilation, and
stenting as needed with no adverse outcomes from the sec-
ondary procedure. Chi et al.5 reported lower anastomotic
stricture rates associated with robotic hepaticojejunostomy
reconstruction 0% (0/70) versus laparoscopic 1.43% (1/70). In
contrast, Yeung et al.2 reported an anastomotic stricture rate
of 0% (0/21) associated with laparoscopic hep-
aticoduodenostomy versus 12% (4/33) for laparoscopic hep-
aticojejunostomy reconstruction. In the adult population,
Yoon et al.6 in their single-institution retrospective review of
laparoscopic versus robotic choledochal cyst excision and
hepaticojejunostomy reconstruction reported 8.7% (2/23)
versus 18.8% (3/16) stricture rates. There appears to be variable
rates of anastomotic stricture after biliary reconstructing in
the literature which is most likely multifactorial. Consider-
ations that play a role include surgical technique, type of
reconstruction, pediatric patient age/size, length of follow-up,
and learning curve (in the setting of recent increasing use of
the robotic approach over the last decade); however, it is not
clear based on the current literature. Ultimately, the wide
variability is likely due to the low incidence rate of pediatric
choledochal cysts and resulting small sample size in each of
these studies.
Historically, the surgical treatment of pediatric chol-
edochal cysts was through an open surgical approach which is
associated with shorter operative times compared to mini-
mally invasive approaches.7,8 For open procedures, Xie et al.
reported an average operative time of 115.88  13.41 min,
while Kim et al. reported an average operative time of
327  73 min.7,8 Open procedures tend to be faster likely due to
the decreased technical requirements to create the hepatico-
enteric anastomosis.9
Over the last decade, laparoscopy has allowed for a mini-
mally invasive approach in the pediatric age group with
improved outcomes to include shorter time to feeding,
decreased blood loss, and decreased hospital LOS.10-13
Furthermore, in a broad meta-analysis conducted by Shen
et al., it was found that patients who underwent laparoscopic
surgery for choledochal cysts had decreased postoperative
morbidity, LOS, and blood loss.14 Other benefits of the lapa-
roscopic approach can lead to reduced tissue injury and
improved cosmetic outcome due to its smaller sites of
abdominal entry rather than a traditional laparotomy.
The laparoscopic approach has not been widely adopted
due to the associated technical difficulty when treating a
choledochal cyst. Factors such as limited freedom of
477
movement, rigid instrumentation, and limited workspace
contribute to the surgery’s complexity and high technical
skill requirement.10,15 To help overcome these limitations,
there has been a shift to perform robotic-assisted laparo-
scopic surgery for treating choledochal cysts. In 2006, Woo
et al. performed the first robotic-assisted laparoscopic
choledochocystectomy on a 5-year-old female, and since
then, robotic-assisted surgery has been adopted and studied
in many institutions, primarily in Asia.16-18
Two recent studies compared robot-assisted versus lapa-
roscopic approaches to choledochal cyst excision and hep-
aticojejunostomy biliary reconstruction. Yoon et al.
retrospectively compared 23 laparoscopic to 16 robotic adult
patients (average age 34-37 years) and found no significant
differences in operative time, blood loss, or postoperative
biliary complications. However, they did reveal increased
hospital LOS for the robotic group (14.7 versus 11.4 days) and
increased hospital costs ($7331 versus $6568).6 In contrast, Chi
et al.5 retrospectively compared matched 1:1, 70 robot-
assisted versus laparoscopic choledochal cyst excisions and
hepaticojejunostomy reconstruction in the pediatric popula-
tion (average age 34-36 month). While robotic-assisted sur-
gery had longer operative time than laparoscopic surgery (229
versus 172 min), the group revealed a shorter cyst excision
time (61 versus 71 min), shorter hepaticojejunostomy time (53
versus 64 min), decreased blood loss (6.81 versus 23.24 mL),
shorter postoperatively LOS (6.9 versus 7.9 days), and
decreased postoperative complicated rate (1.4% versus
10.0%).5 The LOS in this study for patients undergoing
robotic-assisted surgery was 8.2  7.5 days compared to
17.3  10.3 days for the laparoscopic group which correlates
with the trend in the literature. Furthermore, while this small
study is not sufficiently powered for a comparative analysis
of outcomes, the laparoscopic and robotic cohorts did
demonstrate similar overall complication rates of 20% and
23%, respectively.
Robotic surgery for choledochal cysts tend to be longer
than laparoscopic surgeries with an operative time difference
of 28.75 min.5,7,17-19 Han et al. reported an average robotic
operative time of 258.5  52.9 min, which was similar to other
reports, whereas Koga et al. reported an average robotic
operative time of 654 min, much longer than any other
available study.17,19 The operative time for the robotic pro-
cedures in this study was 321  84 min compared to laparo-
scopic 267  104 min (laparoscopic converted to open
removed) which correlates with the literature that the robotic
approach has longer operative times. It should be noted that
while there was the one conversion to open in the laparo-
scopic cohort, there were no conversions in the robot-assisted
cohort. In this study, the operative times recorded report time
from skin incision to skin closure as designated by the medical
record limiting the ability to specifically evaluate various
portions of the procedure such as robotic console time. Of
note, at our institution, we did transition from the da Vinci SI
Surgical System to the Xi in 2019 (Tables 2 and 3). Although
only two patients underwent the procedure with the Xi model
and thus it is difficult to draw conclusions, we would expect
that operative times with the Xi model should improve over
time given its technical advantages with regard to setup and
docking.
478 j o u r n a l o f s u r g i c a l r e s e a r c h
n o v e m b e r 2 0 2 3 ( 2 9 1 ) 4 7 3 e4 7 9

While robot-assisted laparoscopic surgery tends to be the rare incidence rate of pediatric choledochal cysts. Because
longer, the technique does overcome some of the limitations of the disease’s infrequency, all studies in the past have been
of laparoscopic surgery with significant improvements in retrospective in nature. This study attempts to provide a
visibility and 3D depth perception, greater range of motion, comparison of robotic and laparoscopic experiences at our
tremor filtration, and motion scaling. All these features allow institution. Although the laparoscopic and robotic cohorts are
for easier and safer manipulation, which is particularly too small and mismatched to provide meaningful compara-
important in pediatric patients with smaller abdominal tive analysis, we include a descriptive statistical analysis of
domain, specifically when facilitating the critical and delicate the two cohorts. There remains a need for a multi-
hepaticoenteric anastomosis.17,20 institutional randomized prospective study to compare peri-
However, there are limitations to the robotic platform operative outcomes regarding the different surgical ap-
compared to laparoscopy. First, laparoscopy is faster, likely proaches (robotic versus laparoscopic) and reconstruction
due to the ability to switch instruments quicker, which can techniques (hepaticojejunostomy versus hep-
happen often during the procedure, in addition to time aticoduodenostomy) for pediatric choledochal cysts.
required to dock the robotic platform. Laparoscopy provides
haptic feedback which can be beneficial during the mobiliza-
tion and manipulation of the choledochal cyst and duodenum.
While a robotic platform can allow a surgeon easier manipu- Conclusion
lation in a smaller cavity, total patient size should be a major
consideration, as the robotic system itself is a large machine Robot-assisted laparoscopic choledochal cystectomy with
that may not be suitable for certain patients due to space hepaticoduodenostomy is associated with overall good out-
constraints and limited range of energy devices.17 Addition- comes with the most common long-term complication being
ally, a robotic procedure has a higher surgical cost.20 anastomotic stenosis with associated cholangitis requiring
Finally, pediatric choledochal cysts have a lower incidence endoscopic dilation and stenting. Pediatric choledochal cysts
in the United States compared to Asia. Furthermore, the use of remain a rare disease and although limited by the small
robotic-assisted approach and the hepaticoduodenostomy cohort sizes, this study is the largest American case series to
reconstruction is significantly less reported in American sur- report on the robotic surgical treatment of pediatric chol-
gical literature.11,15,21 Two systematic reviews compared edochal cysts. Further multi-institutional randomized pro-
hepaticoduodenostomy versus hepaticojejunostomy.22,23 Pa- spective studies are needed to better understand outcomes
tients treated with hepaticoduodenostomy had higher rates of related to different surgical approaches.
biliary reflux than hepaticojejunostomy but shorter hospital
stay, shorter operative time, and decreased bleeding. The rate
of reintervention was comparable. The surgeons at our insti-
tution standardized the use of the hepaticoduodenostomy in
Author Contributions
their practice to limit the reconstruction to one anastomosis
All authors contributed significantly to the drafting of this
with associated benefit of decreased anastomotic leak risks
manuscript in all phases.
(one anastomosis versus two) and shorter associated operative
time. Another potential benefit is that hepaticoduodenostomy
reconstruction results in a more anatomic configuration,
allowing subsequent ERCP for diagnostic and treatment pur-
Disclosure
poses. In this series, two patients required ERCP, at 61 and
260 days postoperatively, to treat symptomatic anastomotic
The views and opinions expressed in this article are those
strictures. While the hepaticoduodenostomy reconstruction
solely of the authors and in no way reflect the opinions of the
facilitated this approach, it should be noted that our series had
United States Government. In addition, Dr Russell Woo is an
a relatively high stricture rate. Existing literature is unclear as
Associate Editor for the Journal of Surgical Research; as such,
to whether hepaticoduodenostomy or hepaticojejunostomy
he was excluded from the entire peer-review and editorial
reconstruction has an advantage with respect to stricture.
process for this manuscript.
Based on our experience, the robotic platform can be used
to facilitate the biliary-enteric reconstruction due to its tech-
nical ease and speed. The hepaticoduodenostomy recon-
struction is associated with rare cholangitis and biliary reflux Funding
complications while allowing for the main benefit of an
endoscopic approach for complications should they arise The authors received no funding or other support for the
(versus open surgical revision of a hepaticojejunostomy stric- creation of this manuscript.
ture). Additionally, the lack of Roux-en-Y anatomy precludes
the possibility of its associated complications (i.e., internal
hernia). With these advantages, hepaticoduodenostomy
reconstruction can be considered as a primary option when Meeting Presentation
approaching pediatric choledochal cysts.
This study is limited by its retrospective nature, being at a This study was presented at the Society of Asian Academic
single institution, and the small sample size associated with Surgeons Annual Meeting 2022 in Honolulu, Hawaii.
 nguyen et al
robotic peds surgery choledochal cysts 479

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