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Hamad et al. Mini-invasive Surg 2023;7:16 https://dx.doi.org/10.20517/2574-1225.2023.03 Page 3 of 10

Green (ICG) is a near-infrared spectrum fluorescence used in laparoscopic and robotic surgery that has
been shown to be useful in delineating anatomical structures [17,18] . The dye is almost completely metabolized
by the liver and excreted through the bile ducts, which is why it can be useful in technically-complex
[17]
procedures such as the surgical resection of CC . While well-described for hepatic and pancreatic
resection, there was a paucity of reports on the use of the MIS approach in the treatment of CC. This is the
first comprehensive review of laparoscopic and robotic assisted approaches for the surgical resection of
choledochal cysts. Previous reviews have either compared only one approach or have combined the
[19]
[20]
results of previous literature focusing on only one aspect of the procedure . Due to the technical
complexity and steeper learning curve of minimally invasive biliary reconstruction, the MIS approach has
not been as widely adopted in biliary surgery. We herein review the use of laparoscopic and robotic-assisted
surgery in the treatment of CC.

METHODS
A comprehensive review of the literature was performed using MEDLINE/PubMed and Web of Science
databases with a search end date of December 29, 2022. In PubMed, the terms “choledochal cyst”, “biliary
cyst”, “robotic assisted”, “laparoscopic” and “minimally invasive surgery” were used. Articles published in
English were assessed according to these eligibility criteria. Duplicate publications, single case reports,
review articles and studies with no reported treatment were excluded. An expert review of the available
literature was performed, and the most relevant and informative publications were identified for inclusion.
Data were used to review the use of laparoscopic and robotic-assisted surgery in the treatment of CC
[Figure 1].

Laparoscopic choledochal cyst resection
Background
The first ever reported laparoscopic choledochal cyst resection (LCCR) was described by Farello and
colleagues in 1995 with a successful hepatic-jejunal roux-en-y loop anastomosis in a six-year-old girl . In
[21]
subsequent years, the laparoscopic approach was progressively adopted and described by many surgeons
and institutions to treat CC [Figure 2]. Laparoscopy has been repeatedly demonstrated to be safe and
feasible for the treatment of CC. However, this approach is technically complex and therefore has a
considerable learning curve.

Outcomes
Since first being described by Farello and colleagues, LCCR has been reported in numerous case series, case-
control studies, and meta-analyses. In the early 2000s, single-center studies demonstrated the feasibility of
the laparoscopic approach among adult patients with various types of CC [22-24] . In the last decade, larger case
series demonstrating the safety and feasibility of LCCR were published [25-29] . Hwang and colleagues described
their early experience in 20 patients with Type I and IV CC undergoing LCCR. Similar morbidity and
mortality rates were noted among patients undergoing LCCR compared with historical data from patients
in the literature who had undergone an open approach; however, LCCR was associated with longer
operative times and high conversion rates, largely attributable to the learning curve given the technically
challenging nature of the procedure . Similarly, Jang and colleagues reported comparable short-term
[25]
[26]
outcomes vs. the open approach while demonstrating better cosmetic and functional results . In a separate
study, Aly and colleagues compared using LCCR among patients undergoing surgical resection during two
time periods (1996-2005 vs. 2006-2015). The authors noted improved operative outcomes among patients
treated in the more recent time period with no conversions to open resection and only one case requiring
hand assistance during laparoscopic resection; the improved operative outcomes were attributed to surgeon
experience and improvement in surgical skills over time .
[29]