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Ting: Liver Cyst

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In November 2018, 35-year-old Ting Yi was in the middle of her work day as an investment associate when she suddenly felt a sharp, searing pain in her upper right abdomen. “It was really intense, especially toward my back,” she said. The pain lasted through the day and followed her home to North Haven. “I thought it might be a stomach virus,” Ting said. “But the pain kept coming and going for five days – too long for a stomach virus.”

She went to her local hospital’s emergency department, where bloodwork revealed that her liver enzymes were elevated. An ultrasound detected not only bladder stones but a cyst in her bile duct. She consulted with a general surgeon, who said that her cyst was very unusual and that she would be better served by a liver specialist at Yale.

That specialist was Charles Cha, MD, FACS, Associate Professor of Surgery (Oncology and Gastrointestinal). An MRI confirmed Cha’s diagnosis of a type I choledochal cyst, a congenital enlargement of the bile duct. “It’s a relatively rare condition,” Dr. Cha said. “It’s something we consider a pre-malignant situation, meaning that between 40 to 80 percent of patients with this type of cyst, over the course of their lifetime, will have a progression to cancer.”

Ting felt overwhelmed by her diagnosis. “I was scared about the cancer risk,” she said. “But both Dr. Cha and his nurse told me, ‘We will take care of you.’”

The recommended course of treatment is surgical removal of the cyst and resectioning of the bile duct. “It’s not a small operation,” Dr. Cha explained. “The bile duct travels all the way from inside the undersurface of the liver down to the head of the pancreas, where there are a lot of major vessels and major structures that have to be carefully preserved during the operation. Open surgery requires an incision all the way across the upper abdomen and down the midline.”

As Director of the Minimally Invasive Hepatopancreatobiliary Program, Dr. Cha has a special interest in employing laparoscopic and robotic surgical techniques for the liver, pancreas, and stomach. He is one of the few surgeons in the Northeast with extensive experience in using the da Vinci surgical robot in this specialty. Although there were no published cases in the U.S. of the da Vinci robot being used for a type I choledochal cyst, Dr. Cha thought that Ting was a good candidate. “Robots provide access to hard-to-reach areas and have a 360-degree range of motion, which allows me to move the needle and manipulate tissue to a much finer degree,” he said. “For this surgery, I would need to do very fine suturing—finer than a hair on your head—high on the undersurface of the liver, above the rib cage, in order to reconstruct the bile duct.”

Ting was fascinated by the prospect of robotic surgery. “I have a PhD science background and did post-doctoral work at Yale, and so I had a lot of questions, very technical questions, for Dr. Cha,” she said. “He always took his time to answer all of my questions and explain things very clearly.”

During Ting’s eight-hour surgery in January, Dr. Cha sat at a console apart from the patient. He used a joystick to manipulate the three robotic arms plus a dual-channel camera arm, which provides a 3D magnification of the surgical site. He pressed a foot pedal to switch between the arms. “There’s a misconception that robotic surgery is something automated,” Dr. Cha said. “There is nothing automated about it.” At surgery’s end, Ting had only five small incisions ranging from five to 12 millimeters – one-fifth to one-half an inch.

Ting made a remarkably swift recovery from her surgery. She returned home from the hospital after only three days – instead of the expected five to seven – and went off pain medication two days later. She did experience some vomiting, as was expected, but she was ready to return to work after only three weeks, half the usual recovery time.

“On a follow-up appointment, Dr. Cha told me, ‘Don’t push yourself. I don’t know if you realize that this was a major surgery,’” Ting said. “I know that it was major. But based on my physical recovery, it seems my body didn’t realize this was major. This state-of-the-art robotic surgical technique and Dr. Cha’s incredible skill set led to my amazing recovery.”

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