Technical essentials of thorough mobilization of left and right portal veins during laparoscopic Kasai operation

Abstract

Objective To explore the technical essentials of thorough mobilization of left and right branches of portal veins for type Ⅲ biliary atresia (BA) during laparoscopic Kasai portoenterostomy (LKPE). Methods The clinical data of 28 children with type Ⅲ BA undergoing laparoscopic Kasai procedure from June 2013 to June 2017 were retrospectively analyzed. There were 20 boys and 8 girls with a mean age of (68.5±16.5)(30-136) days and a mean body weight of (4.6±1.5)(3.0-7.0) kg. And the specific ages were 30-90 days (n=24) and 90-136 days (n=4). Percutaneous suturing was utilized for suspending round ligament and retracting liver. Fundus and neck of gallbladder were sutured to elevate liver for exposing portal hepatis when necessary. Fibrous cord and hepatic vessels were thoroughly mobilized. Then two rubber bands were placed around the branches of portal veins and hepatic arteries. Portal hepatis was exposed by stretching laterally with two elastic rubber bands. Finally fibrous cord was removed. Results All operations were completed successfully. Only two cases were converted into open surgery by a micro transverse incision at right subcostal space. The admission age was (68.5±16.5)(30-136) days. And the distribution was 30-90 days (n=24) and 91-136 days (n=4). Mean laparoscopic duration was (218.5±15.8) (194-260) min, time of thorough mobilizing left & right branches of portal vein (114±12.5)(113-132) min and mean duration of Kasai portoenterostomy (35±4.5)(28-42) min. All cases survived without any intraoperative complication. Intraoperative blood loss was minimal without any necessity for blood transfusion. One case died of respiratory failure at 1 week post-operation. The mean follow-up period after discharge was 24.4 (6-57) months. In 22 cases, total bilirubin returned to normal. In another two cases, bilirubin levels declined markedly and were further monitored. Three deaths occurred due to recurrent cholangitis and liver failure at 10, 16, 35 months postoperatively. Conclusions Laparoscopic thorough mobilization of left and right portal veins for exposing portal hepatis during Kasai portoenterostomy may be performed safely and successfully with encouraging outcomes and a low conversion rate. Key words: Biliary atresia; Laparoscope; Mobilization; Portal vein