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Page 2 of 10 Hamad et al. Mini-invasive Surg 2023;7:16 https://dx.doi.org/10.20517/2574-1225.2023.03

Conclusion: A minimally invasive approach to CC likely has improved perioperative outcomes with shorter LOS,
return to baseline function, as well as improved cosmesis vs. OCCR. Longer operative times with minimally invasive
approaches to CC have been attributed to steep learning curves, which have improved over time as surgeons
become more facile with this technique. Both LCCR and RCCR have demonstrated similar rates of long-term
postoperative complications and overall survival when compared to OCCR.

Keywords: Choledochal cyst, minimally invasive surgery, laparoscopy, robotic-assisted

INTRODUCTION
Choledochal cysts (CC) are abnormal cystic dilations within the extrahepatic and intrahepatic biliary tree.
CC are more common in East Asian populations and have a four-times higher incidence in female
patients . The most widely accepted classification system for CC was proposed in 1959 before being revised
[1]
in 1977 to include intrahepatic cysts then further refined in 2003 to incorporate the presence of an abnormal
pancreaticobiliary junction . According to the Todani classification system , type I cysts are characterized
[5]
[2-4]
by a cystic or fusiform dilation of the common bile duct (CBD) (IA involves the CBD and part or all of the
common hepatic duct and extrahepatic portions of the left and right hepatic ducts, IB is a focal segmental
dilation of the distal CBD, IC is a dilation of all the extrahepatic ducts, and ID is a cystic dilation of CBD
and cystic duct), type II cysts are true diverticula of the extrahepatic bile ducts, type III cysts (i.e.,
choledochocele) are cystic dilations limited to the intraduodenal portion of the distal CBD that can be lined
by either duodenal or biliary epithelium and are not associated with any malunion, type IV cysts are defined
by the presence of multiple cysts and are divided into subtypes based on intrahepatic bile duct involvement
(Type IV A - both intrahepatic and extrahepatic cystic dilations vs. Type IV B - only extrahepatic cysts);
type V CC are defined by one or more cystic dilations of the intrahepatic ducts without extrahepatic
[6]
involvement and is termed Caroli disease . When Type V CC is associated with congenital hepatic fibrosis,
it is termed Caroli syndrome and is typically inherited as an autosomal recessive trait . In a subset of
[7]
patients, CC can be associated with symptoms such as abdominal pain, nausea, vomiting, fever, and
jaundice, consistent with cholangitis. Adult patients with CC may more commonly present with
pancreatitis. Patients with type I, II, or IV cysts should typically undergo surgical resection due to the risk of
malignancy, recurrent cholangitis, or recurrent pancreatitis. Patients with intrahepatic type IV cysts will
often undergo a partial hepatectomy for the resection of the intrahepatic portion of the cyst which may be
[8]
difficult to treat . Among patients with CC, the incidence of malignancy approximates 10% . In general,
[9]
the preferred operative approach is surgical resection of the CC with a Roux-en-Y hepaticojejunostomy. A
hepaticoduodenostomy is not typically performed in adults due to anatomic reasons as well as to avoid
reflux into the biliary tree. Of note, patients with type III cysts require endoscopic treatment only if
symptomatic. Patients with type V cysts generally receive supportive treatment unless the patient develops
complications such as recurrent cholangitis or sepsis; treatment of type V cysts generally requires liver
transplantation in the setting of progressive biliary cirrhosis and portal hypertension.

The application of minimally invasive surgery (MIS) has transformed various surgical subspecialties. Due to
technological advancements, improved multidisciplinary planning, and advanced imaging techniques, MIS
has been increasingly utilized for various benign and malignant hepatopancreatobiliary (HPB)
indications [10-16] . After the adoption of laparoscopy in the 1990s, published literature comparing the
minimally invasive approach to open surgery demonstrated improved outcomes such as shorter hospital
length of stay (LOS), lower morbidity, improved cosmesis, and more rapid return to baseline functional
status without compromising oncological outcomes. The robotic platform overcame some of the limitations
of laparoscopy as it has the added benefit of three-dimensional visualization, stabilization of tremors,
reduced operative fatigue, and improved ergonomics from the console-surgeon interface. Indocyanine