| Purpose: Congenital choledochal cyst (CCC) is a common biliary deformity in pediatric population, involves not only the common bile duct, but the intra-hepatic bile duct, and is always accompanied by pancreaticobiliary maljunction (PBM). The accepted treatment is extrahepatic cystic excision with hepaticojejunostomy. With the advancing of minimally invasive surgery (MIS), the laparoscopic approach has been applied to choledochal cystic excision and Roux-en-Y hepaticojejunostomy. However, the procedure is still challenging for the technical complexity of video-guided operation and the difficulty in performing hand-sealing hepaticojejunostomy. In this study, we summarized our surgical techniques and outcomes of laparoscopic procedure for choledochal cyst, to evaluate the feasibility and safety of laparoscopic MIS technique for CCC, explore the corresponding strategy of perioperative complications and provide feasible suggestions for avoiding intra-operative accidents, decreasing morbidity rate, improving the post-operative recovery.Methods: We retrospectively analyzed the clinical data of 82 children who had undergone laparoscopic choledochal cystic excision and Roux-en-Y hepaticojejunostomy in our institute from 2002 to 2010. There were 18 boys and 64 girls with the male: female rate was 1:3.6. The mean age was 4.06±3.76 years, with a range of 5 months to 14 years. Diagnosis was made by clinical manifestations with ultrasound, CT scan, magnetic resonance cholangiopancreaticography (MRCP), or intraoperative cholangiogram (IOC). The operation was carried out using 4 ports, and the first 5mm or 10mm trocar was placed via a small incision in the umbilicus, and then carbon dioxide (CO2) pneumoperitoneum was created. Under the laparoscopic visualization, three additional 5 mm trocars were placed at the right hypochondrium anterior axillary line, right midabdomen and left hypochondrium on the midclavicular line. In order to obtain an accurate delineation of the ductal anatomy of choledochal cysts, we first performed an IOC by puncturing or catheterizing the gallbladder. Then the extra-hepatic cyst was divided from the hepatic artery, the portal vein, the duodenum and the pancrease. The whole dissection procedures were done under the guidance of the IOC so as not to injure the cholangiopancreatic union when the distal CBD was dissected, the proximal dissection was then carried out all the way to above the cephalad end of the extrahepatic cyst and the level of resection was extended up to the confluence of the right and left hepatic ducts. If intrahepatic ductal stricture was suspected, endoscopic examination of the bile duct was performed by impelling 5-mm laparoscope through the hepatic ductal orifice at the hilum. Further the resection of stenotic duct, or even taking the confluence of the hepatic ducts, or ductoplasty must be performed to create a large stoma. The proximal jejunum was exteriorized through the enlarged umbilical incision to perform end-to-side jejuno-jejunostomy, and then the bowel returned to the peritoneal cavity. After reestablishing pneumoperitoneum, the Roux-en-y limb was passed retro-colic up to the porta hepatis, and the hepatico-jejunostomy was performed by hand-sealing technique under the laparoscopic visualization. A drainage catheter was placed at the hilum anastomosis through tight hypochondrium in the end. Data about time taken for total operation, choledochal cystic classifications, intra- and post-operative complications were collected.Results: Of the 82 children, 40 cases manifested cystic dilation and 42 cases fusiform dilation. IOC was successfully performed in 63 cases, and PBM was confirmed in 57 cases. According to Todani's classification, the type Ia was 35, Ib 3, Ic 26, III 1 and IV-a 16. Laparoscopic procedures were performed successfully in 79 cases. Three patients were converted to open procedures because of 1 case with gaint cyst, 1 type III cyst and 1 bleeding due to inflammatory hemangioma. There were 16 cases with IV-a CCC, the stricture of common hepatic duct was found in 8 cases that the stenotic segment was splited or excised for a wide hepaticojejunostomy, a constrictive confluence of the bilateral hepatic duct was incised in 4 cases with a bi-ductal cystojejunostomy achieved at the bifurcation, a septum was found at the opening of the right hepatic duct in 2 cases that excised through the hilar bile duct and a downstream stricture of the dilated left hepatic duct was incised from the hilum to the dilated segment along the lateral wall in 2 patients forming a long intrahepatic cystojejunostomy in an oblique orientation. In additional, 12 cases with protein plug or stone occlusion in the common channel, 7 complicated suppurative inflammation, 2 with spontaneous rupture and 2 with heterotopic pancrease in jejunum were managed meanwhile. The mean operative time was 264.9±88.8 minutes, and the average postoperative hospital stay was 9.7±2.9 days. 8 intra- or peri-operative complications were noted, injury to portal vein in 1 case (repaired intraoperatively without convertion), temporary bile leakage in 5(managed successfully in a conservative way), biliary loop volvulus in 1( reoperation was needed), and stress ulcer in 1(cured by conservative therapy). During a follow-up of 2 months to 8 years, 1 patient developed hepaticojejunal anastomotic stricture(reoperation was needed), 1 patient developed incision hernia(reoperation was needed), and 2 patients developed bowel ileus(managed successfully by conservative therapy). There were no mortality rate in this series.Conclusions: Laparoscopic intraoperative cholangiography may identify anatomic variation and complicated bile duct stricture of CCC. With the magnification of the endoscope, it could help to accomplish the radical excision of the cyst, avoid injuring the pancreato-biliary union and manage coexisting hilar bile duct stricture. Dissecting the posterior cyst wall from the underlying portal vein is the most crucial part of the procedure. In patients with type Ia CCC, a horn-like proximal cuff of cyst is retained for small-size ducts to aid in the hepaticojejunostomy anastomosis. While IV-a CCC is identified, a slit on one end of the small ducts from the hilum to the dilated intrahepatic segment will render the anastomosis in an oblique orientation, widening the lumen. Laparoscopic cholangioenterostomy at the porta hepatis or intrahepatic areas is safe and effective. Morbidity and mortality rates after laparoscopic management are comparable with the results of the open procedure. Laparoscopy for CCC is feasible, faster recovery, improved cosmesis etc, and can be safely applied in pediatric populations with satisfactory result.
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