title: Hybrid laparoscopic-robotic management of type IVa choledochal cyst in the setting of prior Roux-en-Y gastric bypass: video case report and review of the literature.
abstract: BACKGROUND
  Choledochal cysts are rare congenital disease of the biliary system. The recommended treatment of these lesions is surgical excision with biliary enteric reconstruction. In patients with normal anatomy, Roux-en-Y hepaticojejunostomy is preferred. However, different options in biliary reconstruction must be entertained in those with abnormal anatomy.
  
  
  METHODS
  Our patient is a 39-year-old female, who during workup for bariatric surgery two years prior to presentation, was found to have a 6 cm dilation of her common bile duct. She underwent a laparoscopic Roux-en-Y gastric bypass (LRYGB) in 2011 at an outside facility, with no planned intervention on her biliary tree. Ultimately, she developed right upper quadrant pain two years following her RYGB. Upon further workup including right upper quadrant ultrasound, an extrahepatic choledochal cyst was confirmed and she was referred to our institution for definitive care.
  
  
  RESULTS
  The patient was taken to the operating room for resection of the choledochal cyst with hepatoenteric reconstruction. The dissection and resection of the cyst commenced laparoscopically. After performing a generous Kocher maneuver, we demonstrated that there was adequate mobilization of the duodenum to perform a tension free hepaticoduodenostomy, which was performed robotically. Her postoperative course was uneventful, and she was discharged home on postoperative day 3. At one month follow up, the patient was doing well with symptom resolution. Her final pathology revealed a choledochal cyst which was negative for dysplasia or carcinoma. Long-term follow up has been recommended with yearly alkaline phosphatase levels.
  
  
  CONCLUSIONS
  Here we present a video of the technical considerations during a robot-assisted laparoscopic biliary reconstruction in a patient with a prior Roux-en-Y gastric bypass with a type IVA choledochal cyst.
authors.affiliation: Department of General Surgery, Cleveland Clinic, Digestive Disease Institute, 9500 Euclid/A10, Cleveland, OH, 44195, USA, juliettac@gmail.com.
authors.forename: Julietta
authors.initials: J
authors.lastname: Chang
authors.forename: R Matthew
authors.initials: RM
authors.lastname: Walsh
authors.forename: Kevin
authors.initials: K
authors.lastname: El-Hayek
mesh_terms: D000328:Adult; D000713:Anastomosis, Roux-en-Y; D050110:Bariatric Surgery; D015529:Choledochal Cyst / Q000601:surgery*; D003135:Common Bile Duct / Q000601:surgery; D004210:Dissection / Q000379:methods; D004385:Duodenostomy; D005260:Female; D015390:Gastric Bypass; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008099:Liver / Q000601:surgery; D012371:Robotics / Q000379:methods*; D013997:Time Factors