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 ¤  Abstract
 ¤ Introduction
 ¤ Case Report
 ¤ Surgical Technique
 ¤ Discussion
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 Table of Contents     
UNUSUAL CASE
Year : 2021  |  Volume : 17  |  Issue : 1  |  Page : 101-103
 

Robotic transduodenal excision of duodenal duplication cyst: Case report and review


GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India

Date of Submission17-Jan-2020
Date of Decision20-Jan-2020
Date of Acceptance27-Jan-2020
Date of Web Publication24-Feb-2020

Correspondence Address:
Dr. Sunil Kumar Nayak
GEM Hospital and Research Centre, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_17_20

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 ¤ Abstract 

Duodenal duplication cysts are rare congenital anomalies that generally present with abdominal pain and vomiting or may have nonspecific symptoms. Surgical excision is the recommended treatment owing to possible complications, including malignancy. However, difficult locations like the periampullary region are problematic and major surgical procedures, for example, pancreaticoduodenectomy is necessary for total resection. These have a high complication rate resulting in a poor quality of life, especially in children and young adults. Here, we describe a case of duodenal duplication cyst managed by robotic (transduodenal) excision along with a brief review of the literature.


Keywords: Duplication, robotic, transduodenal


How to cite this article:
Nayak SK, Vijay N A, Nalankilli V P, Anand E S, Palanivelu C. Robotic transduodenal excision of duodenal duplication cyst: Case report and review. J Min Access Surg 2021;17:101-3

How to cite this URL:
Nayak SK, Vijay N A, Nalankilli V P, Anand E S, Palanivelu C. Robotic transduodenal excision of duodenal duplication cyst: Case report and review. J Min Access Surg [serial online] 2021 [cited 2021 Jan 27];17:101-3. Available from: https://www.journalofmas.com/text.asp?2021/17/1/101/279121



 ¤ Introduction Top


Gastrointestinal (GI) duplications are congenital anomalies characterised by rarity and significant variation in presenting symptoms, signs, size and location. These may present as solid or cystic tumours, intussusception, perforation, obstruction or GI bleeding. About 2%–12% of digestive tract duplications are constituted by duodenal duplication with a prevalence of about <1/100,000 live births.[1] Duodenal duplications usually do not communicate with the intestinal lumen. Less than 30% of all cases are diagnosed in adults. Surgical resection is the preferred method of treatment for most GI duplications; however, for duodenal duplications cysts, surgical resection may be challenging because of the biliary and pancreatic ductal system in close proximity to these cysts. Although open exploration and resection has been the approach in most of the cases so far, few authors have reported the use of laparoscopy in the management of such cysts. Here, we describe a case of young female diagnosed with a duodenal duplication cyst who was managed by robotic transduodenal cyst excision and Roux-en-Y duodenojejunostomy.


 ¤ Case Report Top


A 26-year-old female presented with pain in the upper abdomen and vomiting for 3 days. There was no history of fever, jaundice, abdominal distension, hematemesis, melena or shortness of breath. On examination, her vitals were stable, with general and abdominal examinations being unremarkable. Contrast-enhanced computed tomography [Figure 1] and magnetic resonance cholangiopancreatography (MRCP) test reports (conducted prior to consulting us) suggested a cystic lesion in the duodenal wall, distal to ampulla with a duplication cyst, retained fluid in duodenal diverticulum or Type III choledochal cyst as differential diagnoses. The patient underwent upper GI endoscopy which revealed periampullary submucosal cystic swelling in the second part of the duodenum (D2), indicating choledochocele or duplication cyst as possible diagnoses. MRCP was repeated at our centre which established the diagnosis of duplication cyst measuring 3.2 cm × 3.7 cm × 5.2 cm in the D2. The patient was planned for surgical intervention. She underwent endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct (CBD) stenting followed by robotic transduodenal duplication cyst excision and duodenojejunostomy after 2 days of ERCP.
Figure 1: Contrast-enhanced computed tomography showing cystic lesion in the wall of duodenum distal to ampulla

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 ¤ Surgical Technique Top


Initially, diagnostic laparoscopy was performed, followed by port placement (as shown in [Figure 2]a and docking of robotic arms. First, the gastrocolic ligament was opened, and the first and second parts of the duodenum were mobilised. This was followed by kocherisation. The first part of the duodenum (D1) was mobilised from the pancreas inferiorly [Figure 2]b and hepatoduodenal ligament superiorly. The D1 was transected at its junction with D2 using a stapler [Figure 2]c. Transected D2 was retracted up using the rubber band technique. After the initial mobilisation of medial portion of D2, the duodenum was opened on its anterior aspect, and the cyst came in view in its entirety [Figure 2]d.
Figure 2: (a) Representative image showing port sites used for surgery (b) mobilisation of duodenum (D1) from the pancreas inferiorly (c) duodenum being divided at D1 and D2 junction using stapler (d) cyst as viewed after opening the anterior wall of the duodenum. Stent can be seen just above it

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Posterior duodenal mucosa over the cyst was incised. The cyst was opened, and contents were suctioned off. Thereafter, the cyst was excised completely [Figure 3]a followed by the closure of the mucosa of the posterior wall with polydioxanone (PDS) 3–0 in a continuous fashion [Figure 3]b. CBD stent was removed, and two staplers were fired [Figure 3]c after taking stay sutures, thereby revising the transection margin and closing the doudenotomy. Duodenum (D2) was covered by approximating omentum to the peritoneum posteriorly [Figure 3]d. Loop of jejunum was brought up, and duodenojejunostomy was performed in end-to-side fashion using intracorporeal sutures with PDS 2–0 continuous sutures. Pneumoperitoneum was deflated after placing a drain in the subhepatic space.
Figure 3: (a) Cyst being mobilized for complete excision (b) posterior wall being sutured with polydioxanone 3-0 interrupted sutures (c) stapler being fired after taking stay sutures to close the duodenotomy (d) omentum being approximated to the posterior peritoneum

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Post-operatively, the patient had a normal recovery. Oral liquids were introduced on the post-operative day (POD) 2. The drain was removed on POD 5, and the patient was discharged on POD 6. Histopathology was consistent with duplication cyst of the duodenum. At 8 months of follow-up, the patient was doing fine.


 ¤ Discussion Top


Although considered to be more frequent in the paediatric age group, the incidence of duodenal duplication is significant in the adult age group as well. Chen et al.[2] in their meta-analysis of 47 cases reported between 1999 and 2009 found an incidence of 40.4%, 21.3% and 38.3% in the age group up to 10 years, 10–20 years and >20 years, respectively. Abdominal pain (80%) was the most common presenting complaint, and pancreatitis was the most common complication. Moreover, there are chances of neoplasia and intraoperative frozen sections of the lining epithelium and stripping of cyst mucosa have been suggested in a few reports.[2]

Duodenal duplications may present as a diagnostic dilemma, with pancreatic pseudocyst being the most common misdiagnosis leading to incorrect management.

Periampullary location of this entity poses a surgical challenge. Jadlowiec et al.[3] reported open surgical exploration in a 59-year-old female wherein the gallbladder was removed, and a biliary Fogarty balloon catheter was inserted into the duodenum through the cystic duct to delineate the ampulla. This was followed by endoscopy. Duodenum was opened, cyst was excised and duodenojejunostomy was done after transecting the small bowel distal to ampulla. Due to complexity involved in surgery, few authors have even recommended a conservative approach towards isolated asymptotic cysts if in difficult locations.[4] Complete surgical resection is the recommended treatment for duodenal duplications if their location allows it without endangering the biliopancreatic ducts. However, if important nearby structures are at risk, conservative surgical approaches, such as partial resection with mucosal stripping[5] or internal marsupialization, have been proposed. Laparoscopic excision of the duodenal duplication cyst was reported by Anderson et al.[6] in one of his three cases suggesting the feasibility of the procedure with smaller incisions and decreased blood loss.

In the present era, minimally invasive surgery is the gold standard for several procedures. Smaller incisions, decreased blood loss and a decrease in the surgical stress response and post-operative ileus result in enhanced recovery post-surgery. However, conventional laparoscopy has its limitations such as the restricted movement of instruments, difficult ergonomics, two-dimensional imaging and others. Robotic surgery, with the use of an articulated instrument, tremor filter and use of three-dimensional imaging tries to minimise the shortcomings of laparoscopy.


 ¤ Conclusion Top


This report highlights the rare occurrence of a duodenal duplication cyst along with its management options. In patients presenting with abdominal symptoms with cystic structures in and around the duodenum, it should be considered as a differential diagnosis. Further, this report illustrates the feasibility of a minimally invasive approach to this condition in properly selected patients along with the application of robotics to overcome the shortcomings of conventional laparoscopy.

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.

 
 ¤ References Top

1.
Carmine N, Mercedes R, Ascanio M, Giovanni C. Duodenal duplication cyst in children: Case report. J Surg Tech Proced 2017;1:1007.  Back to cited text no. 1
    
2.
Chen JJ, Lee HC, Yeung CY, Chan WT, Jiang CB, Sheu JC. Meta-analysis: The clinical features of the duodenal duplication cyst. J Pediatr Surg 2010;45:1598-606.  Back to cited text no. 2
    
3.
Jadlowiec CC, Lobel BE, Akolkar N, Bourque MD, Devers TJ, McFadden DW. Presentation and surgical management of duodenal duplication in adults. Case Rep Surg 2015;2015:659150.  Back to cited text no. 3
    
4.
Hussain A, Singh M, Singh S. Isolated duodenal duplication cyst: A review. Niger J Surg Sci 2015;25:29-31.  Back to cited text no. 4
  [Full text]  
5.
Byun J, Oh HM, Kim SH, Kim HY, Jung SE, Park KW, et al. Laparoscopic partial cystectomy with mucosal stripping of extraluminal duodenal duplication cysts. World J Gastroenterol 2014;20:1123-6.  Back to cited text no. 5
    
6.
Anderson K, Rialon K, Pappas T, Perez A. Evolution of surgical resection for duodenal duplication cyst. CRSLS e2016.000108. DOI: 10.4293/CRSLS.2016.000108.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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