A modified technique of single-incision laparoscopic hepaticojejunostomy for children with choledochal cysts

Abstract

Background: To present a modified laparoscopic surgical technique that works to optimize the surgical view in laparoscopic total excision of choledochal cyst in pediatric patients.

Methods: From June 2015 to June 2017, a total of 48 pediatric cases of choledochal cyst were admitted. Their age ranged from 15 month to 8 years (average 3.5 years). The Todani types were: type I (n = 32) and type IVa (n = 16), according to the diagnostic criteria of ultrasound, abdominal computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP).

Results: Total cystic excision with hepaticoenterostomy was accomplished laparoscopically in 48 cases with our transumbilical single -incision method without conversion to open surgery. Average duration of operation was 200 min (range 170-240 min), average intraoperative blood loss was 9 ml (range 6-14 ml) without the need for blood transfusion. The 72-h postoperative ultrasound reported no abdominal effusion, when the intraperitoneal drainage tube was removed. There was no postoperative complication during the 6 months of follow-up.

Conclusions: We accomplished the same postoperative outcome in laparoscopic total cyst excision with our modified method as that with conventional laparoscopic surgery. This technique allows the operator to have a stabilized surgical view without needing to rely on an assistant to hold up the liver lobe for larger operative space.

Keywords: Anastomosis; Choledochal cyst; Laparoscopy; Minimally invasive surgery; Transumbilical.

Fig. 1

Through a 3-cm incision at the umbilicus, a 10-mm trocar, a 5-mm trocar, and a 3-mm trocar were placed

Fig. 2

The liver was lifted to the abdominal wall and stabilized so that the operative field was enlarged to facilitate visualization of the hepatic porta

Fig. 3

The cyst was separated, and cystic arteries ligated with bulldog clamps

Fig. 4

The cyst was separated from the peritoneum and exposed, which was made easy with the liver lifting and resulted traction

Fig. 5

The cyst wall was punctured and bile drained

Fig. 6

The side-to-side hepaticojejunostomy was completed with extracorporeal anastomosis

Fig. 7

The hepatic Roux limb was placed and secured to the hilum via the tunnel behind the colon

Fig. 8

The anastomosis of the common hepatic duct with the jejunum

Fig. 9

Postoperative umbilical incision