Background : Biliary cystic tumors of the liver are rare and comprise less than 5% of all cystic liver lesions. The intrahepatic intraductal papillary neoplasm of the bile duct (IPN-B) is characterized by communication with the bile ducts and the absence of ovarian stroma to differentiate from mucinous cystic neoplasm (MCN). We present a case of robotic (da Vinci Xi, Intuitive Surgical) enucleation of intrahepatic IPN-B in segment V of the liver.

Methods : An 18-year-old girl presented with a complaint of pain in the right upper abdomen for six months with associated anorexia and undocumented weight loss. CECT and MRI of the abdomen suggested a cystic lesion measuring approximately 50x47mm in segments V of the liver with biliary communication with a differential diagnosis of MCN. Robotic ports were placed in a horizontal line along the umbilicus. Intra-operative ultrasound was utilized to mark the cyst's boundary, and robotic enucleation of the cyst with resection of remnant segment V was performed. Indocyanine green dye was used to delineate biliary communication and vascularity of the adjacent remnant liver. The specimen was retrieved by extending the assistant port.

Results : The total operative time was 210 minutes with ~50 ml of blood loss. She was allowed orally on the first postoperative day (POD). Her abdominal drain was removed on the 3rd POD, and she was discharged on the 4th POD. Her pathology was consistent with IPN-B. At the three-month follow-up, she is doing well.

Conclusions : The dexterity and three-dimensional stable vision of robotic arms helped in the enucleation of the biliary cyst from the difficult location and can overcome the limitation of the laparoscopic and open approach.