How does institutional experience impact outcomes on laparoscopic choledochal cyst surgery: an 11-years experience, challenges, and lessons learned.

UNLABELLED: Surgical treatment of choledochal cyst is technically challenging, including advanced dissection, delicate anastomoses and anatomical variations. In teaching hospitals, the complexity is added to the professional turnover, variability of decisions, and heterogeneous clinical presentations, directly influencing the institutional learning curve and outcomes. METHODS: A retrospective observational study with 44 children submitted to laparoscopic treatment of the choledochal cyst, between March 2014 and June 2025 was conducted. Demographic data, clinical presentation, classification, operative time, reconstruction technique, complications, and length of hospital stay were analyzed comparing early and late institutional experience. RESULTS: From 44 patients, 33 were female (75%), with a mean age of 5.1 years at surgery. The most frequent type of cyst was Todani I (57%), and hepaticoduodenostomy was the preferred reconstruction technique (33 cases), being replaced in recent years by hepaticojejunostomy. Mean operative time was 270 minutes. The biliary leak rate was 22.7%, including also small transient fistulas rapidly resolved spontaneously, without association with type of reconstruction or learning curve. The mean length of hospital stay was 10 days. Some questions and controversy remain unanswered. How different biliary reconstruction techniques impact short and long-term clinical outcomes? Should every biliary leak be considered a true complication? The accumulated experience shows that outcomes can be strongly influenced by the teaching environment, turnover of professionals, number and complexity of cases. Evaluating technical skills, challenges and outcomes allows us to understand the evolution of the learning curve and reinforce the need for simulation strategies of training. CONCLUSIONS: More than surgical results, institutional series reveal learning trajectories and reinforce the importance of sharing and publishing data of individual and regional experiences, especially in countries with lower incidence of pediatric biliary disease. Pointing to technical standardization, centralization of cases and simulated training, may accelerate proficiency acquisition and patient safety in complex surgery.