Laparoscopic Choledochal Cyst Excision Research Articles

To drain or not to drain in Roux-en-Y hepatojejunostomy for children with choledochal cysts in the laparoscopic era: a prospective randomized study

Background/PurposeRoutine drain placement after choledochal cyst (CDC) excision and Roux-en-Y hepatojejunostomy (RYHJ) is commonly practiced to predict and prevent bile/pancreatic leaks and hemorrhage. Recently, laparoscopic excision of CDC has decreased postoperative morbidity. The necessity of drainage has been questioned. We undertook a prospective randomized trial to assess the need for drainage. MethodBetween 2009 and 2011, 121 CDC children were randomized into 2 groups before the laparoscopic RYHJ: drainage group (n = 61) and nondrainage group (n = 60). Patients without severe cyst inflammation, perforated bile peritonitis, common/left/right hepatic duct strictures requiring ductoplasty, or distal cyst deeply embedded in pancreas were included. Normal activity resumption, postoperative hospital stay, complications, and pain scores were analyzed. ResultsOne hundred patients were recruited according to the selection criteria (drainage/nondrainage, 50/50). Normal activity resumption was significantly faster and the postoperative hospital stay was significantly shorter in the nondrainage group. The pain score in the drainage group was significantly higher. On postoperative days 2 and 3, 14% and 38% of the nondrainage group patients were pain free, whereas all the drainage group patients still suffered from pain (P < .01 and P < .001, respectively). The median follow-up period was 12.5 months in the drainage group and 12 months in the nondrainage group. None of the patients developed bile/pancreatic/intestinal leaks. ConclusionWith the laparoscopic approach, no drainage is needed after RYHJ for the majority of CDC children in expert hands. It minimizes postoperative pain and complications, and facilitates recovery.

Laparoscopic Treatment for Choledochal Cysts with Stenosis of the Common Hepatic Duct

Choledochal cyst is an important cause of surgically treated jaundice in infants and children. Although total cyst excision and biliary reconstruction remain the treatment of choice, novel approaches have been developed in the past 2 decades. Neither choledochal cyst duodenostomy nor Roux-en-Y cyst jejunostomy is currently preferred. In order to reduce the incidence of postoperative complications such as recurrent cholangitis, biliary cirrhosis, and chronic inflammation, choledochal cyst excision and Roux-en-Y hepaticojejunostomy or hepaticodudenostomy are now commonly used. Nevertheless, many complications of open surgery are still serious problems and are major causes of morbidity and mortality. Early complications may include bile duct injury caused by mistakenly placed clips, erroneous cutting of bile ducts based on misinterpretation of biliary anatomy, periductal bile leakages that cause edema, fibrosis and secondary stricturing, and ischemia from injury to the right hepatic artery. Bile duct strictures are the most common of the late complications and can develop a few months to many years after surgery. In addition, some concomitant lesions, such as hepatic ductal stenosis, calculus, or embolus in the bile duct, may not be discovered by open procedures and could be the causes of liver fibrosis. With development of the laparoscopic technique, laparoscopic choledochal cyst excision, biliary reconstruction, and Roux-en-Y hepaticojejunostomy have been increasingly used in many countries. A number of European studies have confirmed the safety of laparoscopic cholecystectomy. Mortality rates vary between 0% and 0.1%, and duct injury rates range between 0.2% and 0.6%. Because of the magnification function of the laparoscope and the excellent visualization of tiny structures, we found that the laparoscopic effect on choledochal cysts with stenosis of the common hepatic duct was much better in children. In Asian children, the normal diameter of the common bile duct is 3

Laparoscopic Excision of Type I Choledochal Cyst and Hepaticoduodenostomy in an Adult with Short Bowel Syndrome

Introduction: Although laparoscopic excision of the choledochal cyst is an established treatment option in the pediatric population, only a few cases of laparoscopic excision have been reported in the adult patients. Biliary reconstruction after excision of the choledochal cyst is performed by hepaticojejunostomy in most cases. However, in selected cases, hepaticojejunostomy might not be feasible due to the immobility or inadequacy of the jejunum. The authors present a case of a 62-year-old woman with symptomatic type I choledochal cyst. She had a history of multiple bowel excisions resulting in short bowel syndrome. Laparoscopic excision of choledochal cyst and biliary reconstruction with hepaticoduodenostomy was performed. A video with a run time of 8 minutes 1 second is presented to demonstrate the technique used. Materials and Methods: The patient was placed in the Lloyd-Davies position, with the operating surgeon standing in between the patient's legs. A 12-mm port was inserted with the open technique in the right lumbar region away from the previous scars. Another two 12-mm ports and two 5-mm ports were inserted under direct vision. Adhesions were taken down to facilitate the insertion of these ports. The Calot's triangle was dissected to identify the cystic duct and artery. The cystic duct was ligated and divided. The gallbladder was retracted superiorly to facilitate exposure of the hilar structures. The peritoneum anterior to the choledochal cyst was divided, and the cyst was dissected circumferentially. Distal dissection was performed down to the intrapancreatic part of the distal bile duct before transecting with Endo-GIA staplers. Proximal dissection was continued up to the hilar region, carefully protecting the right hepatic artery and portal vein. The proximal bile duct was then transected just below the confluence. The duodenum was mobilized by an extended Kocher's maneuver to facilitate a tension-free hepaticoduodenostomy. The anastomosis was performed with a single-layer, continuous, intra-corporeal suturing by using polydioxanone 4/0 sutures. The specimen was retrieved with an endopouch. Result: The patient recovered uneventful and was ready for discharge on day 3 after surgery. She remained asymptomatic at 6 months of follow-up. The histopathological examination confirmed the specimen to be a choledochal cyst with no evidence of malignancy. Conclusion: This case illustrates the feasibility laparoscopic excision of choledochal cyst in adults. Hepaticoduodenostomy may be a safe alternative method of biliary reconstruction in selected cases such as this patient with short bowel syndrome. The authors have no conflicts of interest or financial ties to disclose. Runtime of video: 8 mins 1 sec

Laparoscopic Excision of Choledochal Cysts with Total Intracorporeal Reconstruction

There are numerous published reports of laparoscopic resection of choledochal cysts (CDCs), but almost all involve extracorporeal reconstruction of a biliary drainage system. We describe and evaluate the technique of laparoscopic CDC resection with total intracorporeal reconstruction. We reviewed all patients who underwent a laparoscopic CDC resection from March 2005 to January 2010 at Rocky Mountain Children's Hospital and Children's Hospital of New York-Presbyterian. We obtained data on operative time, characteristics of reconstruction, time to initiation of diet, length of stay, complications, and outcome. Thirteen patients (median age 5 years, range 1-16) underwent a laparoscopic CDC excision with total intracorporeal reconstruction. Four ports were used in all cases and no patients required conversion to an open procedure. Operative time ranged from 130 to 325 minutes (median 240 minutes). Median time to initiation of diet was 1 day (range 1-4 days). Median length of stay was 5 days (range 4-8 days). There were no cases of cholangitis; however, 1 patient developed a small bowel obstruction requiring re-operation. Laparoscopic resection of CDCs with total intracorporeal reconstruction is a safe and effective technique. The minimal handling of the bowel appears to minimize postoperative ileus, allows for early postoperative feeding and discharge.

Laparoscopic choledochal cyst excision, hepaticojejunostomy, and extracorporeal Roux-en-Y anastomosis: a technical skill and intermediate-term report in 62 cases

This study aimed to present the authors' technique and the intermediate-term outcome for laparoscopic choledochal cyst excision with Roux-en-Y hepatoenterostomy. This retrospective study investigated 62 children (39 girls and 23 boys) who had undergone laparoscopic resection of choledochal cyst. The average age of the children was 2.3 years. The retrospective data and the following investigations about type of choledochal cyst, surgical technique, conversion rate, morbidity, and mortality were analyzed. Of the 62 patients, 43 (69.4%) showed type 1a choledochal cysts, 16 (25.8%) showed type 1c, 2 (3.2%) showed type 4a, and 1 (1.6%) showed type 4b. Total cyst excision could be performed for 51 of the patients (82.3%). The large cysts were opened on the front wall, then divided circumferentially in 29 cases. The small cysts did not need to be opened before excision in 22 cases. For 11 patients (17.7%), Lilly's (Surg Gynecol Obstet 146:254-256, 1978) technique was adopted, and for 5 patients with a huge cyst, the duodenum together with the head of the pancreas had to be mobilized for visualization of the cyst's lower limit. The hepatic duct was excised, and plastic operation of bile duct was performed for two patients. The mean operative time was 226±41.2 min. Eight patients needed blood transfusion, and conversion was required for one patient. The mean hospital stay was 8±1.5 days, and the mean follow-up period was 38 months. The overall morbidity rate was 8.2% (5/61) including bile leakage (n=1), adhesive small bowel obstruction (n=1), intestinal necrosis (n=1), and cholangitis (n=1). Inflammatory edema anastomotic narrowing occurred in one patient. None of the patients needed surgery due to anastomotic stricture. Laparoscopic choledochal cyst excision, hepaticojejunostomy, and extracorporeal Roux-en-Y anastomosis can be safely and quickly performed for children, with satisfactory intermediate-term results. Extracorporeal Roux-en-Y anastomosis could shorten the operative time.

Management of Type I Choledochal Cyst in Adult: Totally Laparoscopic Resection and Roux-en-Y Hepaticoenterostomy

Background/objectiveCholedochal cysts are congenital dilations of the biliary tree. The accepted mode of treatment is total excision with hepaticojejunostomy. In this retrospective study, we present our technique and results of laparoscopic choledochal cyst excisions. MethodsWe retrospectively studied 45 patients who had undergone laparoscopic choledochal cyst excision in our institutes from September 2006 to August 2009. Data including age, gender, type of cyst, symptoms, surgical technique, conversion rate, morbidity, and mortality were analyzed. ResultsThere were type Ic (cystic) choledochal cysts in 31 patients (68.9%) and type If (fusiform) in 14 patients (31.1%). An anomalous pancreaticobiliary duct junction union was found in 66.7%. Forty percent (18 out of 45) and 37.8% (17 out of 45) cases had stones within the cysts and gallbladders, respectively. The average size of the cysts was 40.3±16.9 cm2. The mean operative time was 307.7±58.0 min, the estimated operative blood loss was 252.3±162.5 ml, and the conversion rate was 8.9%. The mean hospital stay was 8.3±3.2 days. The overall morbidity rate was 17.1%, the reoperation rate was zero, and the mortality rate was also zero. ConclusionsTotally, laparoscopic management of type I choledochal cysts, although technically challenging, is safe and feasible in experienced hands.

Laparoscopic excision of choledochal cysts in children: an intermediate-term report

To assess the intermediate-term result of the use of the minimally invasive technique in the treatment of choledochal cysts in children. This is a retrospective review of all cases of choledochal cyst treated in the tertiary referral centre. The surgical technique is described and all the medical records were reviewed to assess the intraoperative and postoperative complications and follow-up problems. From October 2000 to April 2008, laparoscopic excision and reconstruction were attempted in 37 patients. Laparoscopic surgery was successfully performed in 34. Conversion was required in three patients due to oozing on cyst dissection (two) and bleeding from small bowel mesentry (one) during the early part of the series. Postoperative complications were observed in 15 patients including subhepatic collection (6), bile leakage (3), minor wound infection (4) and prolonged ileus (2). At a mean follow-up of 4.2 years, four patients developed surgical complications including intrahepatic ductal strictures in a type IV cyst (one), stump pancreatitis (one), terminal ileal obstruction from internal herniation (one) and cholangitis (one). The cosmetic result was good in all patients. We conclude that laparoscopic excision and reconstruction can be safely performed in children with a choledochal cyst with satisfactory intermediate-term results.

Laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in symptomatic neonates

Purpose Choledochal cysts require surgical excision, preferably before the onset of cholangitis. Recently, it has become feasible to accomplish the excision laparoscopically in adults and older children. Yet, whether laparoscopic excision of choledochal cyst can be performed safely in symptomatic neonates with choledochal cyst is unclear. We herewith reviewed our experience of laparoscopic excision of choledochal cysts in neonates. Methods We managed 9 neonates with choledochal cysts between April 2003 and February 2007. The choledochal cysts were excised laparoscopically. The Roux-en-Y hepaticojejunostomy was fashioned extracorporeally by exteriorizing the jejunum through the extended umbilical port site. End-to-side anastomosis between the common hepatic duct stump and Roux loop was carried out intracorporeally. The patients were followed up for an average of 26 months. Results The patients presented with jaundice, pale stool, and deranged liver function tests. The diagnosis was confirmed with ultrasonography postnatally. The median operation time was 3.6 hours. There was no operative complication and no conversion. The blood loss was minimal. The recovery was uneventful, and the median hospital stay was 6 days. The liver function tests normalized 3 to 16 weeks postoperatively. No complication was detected at the follow-up visits. Conclusions Our preliminary results show that laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in neonates is both feasible and safe. It curtails further complication of the cysts and reverses the derangement of liver function. In addition, the laparoscopic approach minimizes surgical trauma.

Laparoscopic Choledochal Cyst Excision: Lessons Learned in Our Experience

Choledochal cyst (CDC) is a rare biliary disorder. Surgical treatment consists of CDC excision and biliary-enteric reconstruction. Recently, some institutions have reported successful CDC excision by using minimally invasive techniques. In this study, we report our experience with the laparoscopic management of CDC, with a focus on key operative maneuvers that enhance the likelihood of successful excision. Following institutional review board approval, we performed a retrospective review of patients who underwent the laparoscopic excision of CDC and Roux-en-Y hepaticojejunostomy. Between October 2003 and November 2007, we performed laparoscopic CDC excision in 9 patients (8 female and 1 male). Median age was 4 years (range, 8 months to 16 years). There were 7 type I and 2 type IV cysts, according to Todani's classification. Average cyst size was 4.4 cm (range, 1.3-8.5). The procedures were performed by utilizing four or five trochars. Six of 9 children presented with preoperative pancreatitis, 1 with abdominal pain, 1 with jaundice, and 1 was found incidentally. Three patients required the conversion to laparotomy due to dense adhesions, secondary to pancreatitis. Six patients underwent successful laparoscopic procedures, 5 had complete cyst excisions, and 1 underwent a proximal excision with distal mucosectomy. Of the 3 patients who required conversion, 2 underwent complete excisions; the other underwent a proximal excision, distal mucosectomy. There were no intraoperative complications. One patient had a postoperative bile leak that required an open hepaticojejunostomy revision. Eight patients had an uneventful recovery. Oral feedings were resumed within an average of 3.4 days (range, 2-9). Average time to discharge was 6.1 days (range, 5-12). Average follow-up time was 18 months (range, 4-48). No further laboratory abnormalities were detected in any of the patients. Laparoscopic resection of CDC and Roux-en-Y hepaticojejunostomy in children is an excellent treatment option. Preoperative pancreatitis may cause increased technical difficulty, necessitating a conversion. Proximal excision with distal mucosectomy

Laparoscopic Management of Choledochal Cysts: Technique and Outcomes—A Retrospective Study of 35 Patients from a Tertiary Center

Choledochal cysts are congenital dilations of the biliary tree. The accepted mode of treatment is total excision with hepaticojejunostomy. In this retrospective study, we present our technique and results of laparoscopic choledochal cyst excision. We retrospectively studied 35 patients who had undergone laparoscopic choledochal cyst excision in our institute from 1996 to 2008. Data about age, gender, type of choledochal cyst, symptoms, surgical technique, conversion rate, morbidity, and mortality were analyzed. There were Type 1B choledochal cysts in 27 patients (77%) and Type IVA in 8 patients (23%). An anomalous pancreatobiliary junction was found in 40%. Mean operative time was 295 minutes. Total cyst excision could be done in 26 patients. The conversion rate in our series was 8.5%. The overall morbidity rate was 14.3%, the reoperation rate was 8.5%, the mortality rate was 0%, and the incidence of carcinoma was 8.5%. To minimize the risk of malignancy, total excision of the cyst is ideal, but a small proximal cuff of cyst is retained for small-size ducts to aid in the hepaticojejunostomy anastomosis. A slit on one end of the small ducts will render the anastomosis in an oblique orientation, widening the lumen. Dissecting the posterior cyst wall from the underlying portal vein is the most crucial part of the procedure. Morbidity and mortality rates after laparoscopic management are comparable with published results of the open procedure. Laparoscopic surgery for choledochal cysts is feasible, safe, and even advantageous.

Laparoscopic Resection of Type I Choledochal Cyst in an Adult and Roux-en-Y Hepaticojejunostomy: A Case Report and Literature Review

Choledochal cysts are rare cystic dilatations of the extrahepatic biliary tree, the intrahepatic bile ducts, or both and carry a substantial risk of malignant transformation. Type I choledochal cysts, which involve the entire common hepatic and common bile ducts, represent 80% to 90% of these lesions. We report laparoscopic excision of symptomatic type I choledochal cyst in a 37-year-old woman, and review the literature. Laparoscopic excision of the extrahepatic biliary tree from the hepatic confluence to the anomalous pancreatobiliary junction with en bloc cholecystectomy and reconstruction with a Roux-en-Y hepaticojejunostomy was accomplished. Postoperative recovery was uneventful with a hospital stay of 3 days. She remains well and asymptomatic at 6 months of follow-up. Laparoscopic excision of choledochal cysts may be safely accomplished with a prompt recovery. Further experience with this approach in larger number of patients is justified and long-term follow-up data are needed.

Totally laparoscopic management of choledochal cysts using a four-hole method

Choledochal cyst is a rare benign disease of the biliary tract. However, once diagnosed, it must be excised with the gallbladder because of the risk for cancer developing in the biliary tree, including the gallbladder. This report introduces a new surgical technique for totally laparoscopic excision of choledochal cyst and hepaticojejunostomy using a four-hole method. Between October 2003 and May 2005, the authors performed totally laparoscopic choledochal cyst excision for 12 patients. All the patients except one were women, and the mean age was 37.3 years (range, 17-62 years). According to the Todani classification, there were five type Ia cases, four type Ic cases, and three type IV cases. Choledochal cyst excision and Roux-en-Y hepaticojejunostomy were performed laparoscopically using the four-port technique. The mean operation time was 228 min (range, 150-330 min). No operative or postoperative transfusion was required. An oral diet was started on postoperative day 3. The average length of hospital stay was 5.8 days. There was no major complication associated with anastomosis leakage or obstruction. No patient had an adverse response, as determined by clinical or laboratory evaluation during a 2- to 19-month follow-up period. Considering that choledochal cyst is common among young women, who are especially interested in cosmetic results in addition to complete resolution of medical problems, the laparoscopic management of choledochal cyst may be an attractive treatment option.