Biliary Atresia: Laparoscopic Kasai Portoenterostomy

Abstract

Introduction: Biliary atresia is an obliterating disease of the extrahepatic biliary system that must be corrected surgically through a hepatoportoenterostomy. This procedure was developed by Dr. Morio Kasai in the 1950s and was classically performed as an open surgery.1 In 2002, the first laparoscopic portoenterostomy was reported.2 This approach is described in this video. Materials and Methods: This video shows a laparoscopic Kasai procedure done in a 6-week-old female infant who presented with jaundice and acholic stools. A 10 mm trocar was introduced into the scar of the umbilicus using a modified Hasson technique. Pneumoperitoneum was established using 5 L/min of carbon dioxide under 10 mm Hg of pressure. A 30° telescope camera was inserted into the peritoneal cavity for proper observation. Two 3 mm ports were placed in the right side of the abdomen, whereas 3 and 5 mm ports were placed in the left side. The atretic gallbladder was observed. The grasper was used to retract the fundus of the gallbladder while the area was dissected with hook diathermy. The lymph node at the neck of the gallbladder was dissected and removed so the cystic duct could be followed to its entry into the common bile duct. The atretic gallbladder was then released from the liver bed and used as a retractor while the atretic common bile duct was dissected out to the point it entered the duodenum and divided at its lowest point of entry. The area beneath the duct was further dissected up to the portal plate and carried out on either side until we identified the first branch of the right hepatic artery on the right side and the umbilical point on the left side (where the umbilical vein enters the left branch of the portal vein). The atretic common hepatic duct was excised flat with the liver. Bile was observed flowing from the cut surface. Next, the ligament of Treitz was identified. The small bowel was followed distally to a length of ~25 cm. A 25 cm Roux-en-Y loop was constructed extracorporally after pulling the bowel out through the umbilical incision, then reduced back into the peritoneal cavity. A window was made behind the colon so the Roux limb could be placed in a retrocolic direction. Anastomosis of the Roux limb was then made with the biliary plate. The defect in the colon mesentery was closed, the peritoneal cavity was desufflated, and ports were withdrawn and closed with 2-0 vicryl on UR-6 needles. The skin was reapproximated with Dermabond glue. Total operative time was ~4.5 hours. Results and Conclusions: There were no postoperative complications. The patient started to tolerate oral feeds on post-operative day #4 and was discharged on post-operative day #7 after passing yellow stools. At her 3-month follow-up visit, she was tolerating feeds and passing yellow stools and had normal liver laboratories with a decrease in conjugated bilirubin from 6.6 to 1.8 mg/dL. No competing financial interests exist. Runtime of video: 5 mins 26 secs