This case demonstrates robotic hepatic cyst fenestration and partial hepatectomy for symptomatic giant hepatic cysts involving the right lobe of the liver.

The patient is a 59-year-old female with progressively symptomatic large hepatic cysts identified on cross-sectional imaging, the largest measuring approximately 14 cm. She reported increasing abdominal discomfort and mass-effect symptoms. Imaging demonstrated numerous hepatic cysts predominantly involving the right hepatic lobe, consistent with benign biliary cystic disease.

Because of the size of the cysts and progressive symptoms, operative management was recommended.

The patient underwent robotic diagnostic laparoscopy, intraoperative hepatic ultrasound, cyst fenestration, partial hepatectomy, and cholecystectomy with indocyanine green (ICG) cholangiography and angiography.

Intraoperative ultrasound demonstrated extensive replacement of the right hepatic lobe by a conglomerate of large hepatic cysts, with distortion of the normal hepatic vascular anatomy due to mass effect. The cyst burden involved a substantial portion of the right hepatic parenchyma, making simple fenestration alone insufficient, and therefore ultrasound-guided partial hepatectomy was performed to remove the dominant cyst complex and decompress the remaining cystic structures.

The right hepatic lobe was mobilized, and the planned transection plane was defined using intraoperative ultrasound and fluorescence guidance. Hepatic parenchymal transection was performed using a clamp-crush technique with saline-coupled bipolar energy and advanced vessel sealing devices. A small segment V biliary tributary encountered along the transection surface was repaired with fine suture after identification of a minor bile leak.

Concurrent robotic cholecystectomy with indocyanine green cholangiography was performed to define biliary anatomy and treat coexisting gallstone disease.

Hemostasis and biliary integrity were confirmed using ICG fluorescence imaging prior to completion of the operation.

Final pathology demonstrated:

• Multiloculated simple biliary cysts measuring up to 12 cm

• Background hepatic parenchyma with chronic inflammation, reactive biliary proliferation, and pressure-related fibrosis

• No dysplasia, atypia, or malignancy

• Gallbladder with cholelithiasis and chronic cholecystitis

The patient recovered well following surgery.
A surgical drain placed along the hepatic transection surface was removed prior to discharge, and the patient was discharged home on postoperative day 1.

This case illustrates the role of robotic minimally invasive liver surgery for the treatment of symptomatic giant hepatic cysts, allowing precise parenchymal transection, ultrasound-guided resection, and enhanced visualization of biliary anatomy while minimizing surgical trauma and facilitating rapid recovery.