Robotic-assisted enteric sparing excision of jejunal duplication cyst.

Duplication cysts of the gastrointestinal tract are rare and have varied presentations. Complete excision of the cyst is the treatment of choice, either by the open method or laparoscopic method. Authors describe the case of a jejunal duplication cyst excised by robotic minimally invasive surgery. A more safe and precise excision of bowel duplication cysts without bowel resection is possible with the help of robotic assistance.

INTRODUCTION

Duplication cysts of the gastrointestinal tract are rare and have varied presentations. Total excision of the cyst is the treatment of choice, either by the open method or laparoscopic method. Authors describe the case of a jejunal duplication excised by robotic minimally invasive surgery.

CASE REPORT

A 2-year-old girl child presented with complaints of intermittent pain in the abdomen. The child was diagnosed with an enteric duplication cyst on antenatal scans. On physical examination, the child had a palpable mobile lump in the left lumbar region which was freely mobile, cystic and nontender in nature. A magnetic resonance imaging (MRI) of the abdomen was done which suggested the possibility of an enteric duplication cyst [Figure 1]. The parents were keen on a minimal access option for the surgery, and they were advised about the obvious advantages of a robotic surgery in the child.

Figure 1

Magnetic resonance imaging transverse section with hyperintense tubular structure after injection of contrast

We used 8-mm instruments on the Si system. Intraoperatively, it was found to be a jejunal duplication cyst. Meticulous dissection afforded by the robotic instruments along with excellent magnified view ensured complete excision of the cyst without compromising the blood supply of the adjacent bowel. Thus, we were able to do a robotic bowel sparing excision of a jejunal duplication cyst [Figure 2]. The child was started orals after 6 h and was discharged after 48 h.

Figure 2

Intraoperative image showing dissected jejunal duplication cyst (blue arrow), the loop of jejunum from where duplication cyst is arising (white arrow) and a plane between the two being pointed by the tip of the instrument

The use of the Da Vinci robot in this case not only saved us on operative time but also avoided a bowel resection and anastomosis for the child, thus significantly reducing her morbidity and stay in the hospital.

On 6 months’ follow-up, she is doing well, thriving and has no sequela.

DISCUSSION

Duplication cysts of gastrointestinal tracts are rare anomalies with the incidence of 1 in 4500 newborns. They can occur anywhere from mouth till anus with the most common site being ileum. Two-thirds of them occur in the abdominal cavity with more than half of them being small bowel duplications. Affected sites are the thorax or thoraco-abdomen (10–15%), gastric duplications (7%), duodenum (5–7%), pylorus (extremely rare), biliary tract (extremely rare), small intestine (44%), appendix (extremely rare) and colon (15%).[1]

Embryogenesis of duplications remains controversial. Duplication cysts by definition are in close contact with the gastrointestinal tract from where they originate and derive blood supply. They may be either cystic or tubular and present at the mesenteric border of the bowel. Histological evidence shows the presence of well-developed smooth muscle coats and epithelium of the native tract. Ectopic mucosa, the gastric type being the most common (15%) followed by pancreatic tissue, may be present in 35% of specimens.[1]

Diagnosis can be done by ultrasonography, barium swallow; computed tomography or MRI scans. Duplications can be suspected antenatally if cystic lesions are noted in the foetal abdomen during antenatal ultrasonography scans.[12] The symptoms and signs differ depending on location and presence of ectopic mucosa such as abdominal mass, abdominal distention, constipation, vomiting and respiratory distress. Some of them can be entirely asymptomatic.[3]

Complete excision of duplication cyst is the gold standard treatment. Sometimes, excision of the normal bowel in contact with the duplication cyst is necessary. Excess bowel excision may result in short bowel syndrome. In these cases, stripping of the mucosa of the wall adherent to normal bowel and excision of the remnant cyst is sufficient.[3] Minimally invasive surgery is feasible for duplications with the low rate of complications. It can be done complete laparoscopic or laparoscopy assisted.[3]

Robotic-assisted minimally invasive surgery is the step ahead for the management of duplications and has been used for oesophageal and duodenal duplications.[45] There are no reports available in the current literature about robotic minimally invasive surgery for duplications except those done by Obasi et al.[4] and Ringley et al.[5] for gastric duplications. The three-dimension vision, greater freedom of instrumentation, lack of surgeon fatigue and extreme precision helped to complete the excision more accurately with less operative time and early recovery of the patient.

CONCLUSION

Jejunal duplications can be excised safely and more precisely without resection of bowel using robot-assisted minimal access surgery. This case suggests the immense potential for application of robot-assisted minimal access surgery in paediatric patients thus opening new horizons for expanded application of robotics in children.

’Written informed consent was obtained from the patient for publication of this case report/any accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal’.

Video link for the above surgery- https://www.youtube.com/watch?v=A58yOR8EZ34&t=238s.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.