Safety and feasibility of robotic approach to choledochal cysts in adults: a multicenter European experience

Choledochal cysts (CCs) are rare congenital anomalies of the bile ducts associated with an increased risk of biliary malignancy. Surgical management typically involves cyst excision, cholecystectomy, and Roux-en-Y hepaticojejunostomy. While minimally invasive techniques are gaining popularity, their application for CCs management in adults remains underreported and limited to isolated cases. This study aimed to assess the safety and feasibility of robotic approach for CC excision in adult patients. We conducted a retrospective observational study of 22 adult patients who underwent robotic surgery for CCs across nine European hepatopancreatobiliary centers. Data were collected on perioperative and postoperative outcomes, including operative time, blood loss, complications, and hospital stay. The cohort included 22 patients with a median age of 51.5 years (IQR 38-61). Seventeen cases (77.5%) were classified as Todani type I, four (18%) as type III, and one (4.5%) as type IVb. The median operative time was 337 min (IQR 236-449), with a median blood loss of 50 mL (IQR 50-100). The median hospital stay was 6 days (IQR 5-9). Postoperative complications occurred in 6 patients (27%), including 3 cases (14%) of biliary leakage, 1 case of bleeding (5%), 1 case of abdominal collection (5%), and 1 case (5%) of pancreatic fistula. Two of these patients (9%) required reoperation (Clavien-Dindo IIIb). No malignancies were found on pathologic examination. This multicentric analysis demonstrates the feasibility and safety of robotic surgery for CCs in adults, achieving precise excision and reconstruction with minimal morbidity. However, variability in reconstruction techniques highlights the need for standardization. Further multicenter, long-term studies are essential to validate the superiority of robotic approaches over traditional methods.