Robot Assisted Surgery for Choledochal Cyst
For the child with a choledochal cyst the treatment of choice is cyst excision with hepaticoenterostomy [1]. Traditionally this has been performed as an open procedure with hepaticojejunostomy. In 1995, the first report of this condition being treated by
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Naved K. Alizai, Michael J. Dawrant, and Azad S. Najmaldin
15.1 Introduction For the child with a choledochal cyst the treatment of choice is cyst excision with hepaticoenterostomy [1]. Traditionally this has been performed as an open procedure with hepaticojejunostomy. In 1995, the first report of this condition being treated by minimally invasive laparoscopic surgery was published [2]. Initially the uptake of this procedure was slow, because it is a technically demanding procedure. However the last 7 years have seen a marked upsurge in the application of laparoscopic treatment of choledochal cyst with the publication of some large [3–5] and some staggeringly large series [6–8] from centres in South-East Asia, where the condition is more prevalent. The minimally invasive approach has clearly become their standard approach. We adopted this technique in 2007. However, as a department with an interest in robotic surgery and providing supra-regional paediatric liver care, in 2009, we made the transition from conventional laparoscopic to robot
N.K. Alizai (*) • M.J. Dawrant • A.S. Najmaldin Children’s Liver Unit, Leeds Children’s Hospital, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK e-mail: [email protected] A.S. Najmaldin Department of Paediatric Surgery, Leeds Children’s Hospital, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
assisted excision of choledochal cyst and Roux- en-Y hepaticojejunostomy. This new technique has become our standard approach for treating patients with choledochal cysts [9, 10].
15.2 Operative Technique As part of the patient’s preoperative work up we advocate a detailed MRCP (Fig. 15.1a, b) to map the ducts and any possible strictures. Given the limited working space in infants and small children, we prefer the use of three arms of the standard da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA): using one optic and two working arms. The patient is positioned supine with a slight head up tilt (reverse Trendelenburg), with a nasogastric tube and a urinary bladder catheter. Prophylactic intravenous antibiotics (Co-Amoxiclav) are given to cover the perioperative period. The theatre setup is similar for all robotic assisted hepatobiliary procedures. The operating table may have to be moved and turned around to suit the theatre environment and optimise safe surgical and anaesthetic access. The patient-side cart is placed above the right shoulder and the vision cart further down to the right hand side of the patient. The assistant sits comfortably at the patient’s left-hand side. The scrub nurse and their instrument trolley are also positioned on the left, close to the foot of the table. Our technique with port placement has developed with time. Initially we used to place a
© Springer International Publishing Switzerland 2017 G. Mattioli, P. Petralia (eds.), Pediatric Robotic Surgery, DOI 10.1007/978-3-319-41863-6_15
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Fig. 15.1 A typical Type 1c (a) and Type 1f (b) cyst
12 mm port through an infra-umbilical curved inci
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