Laparoscopic resection of congenital choledochal cyst, hepaticojejunostomy, and externally made Roux-en-Y anastomosis

The authors present a 3-month-old patient with a congenital choledochal cyst, which was asymptomatic until treatment. On laparoscopy, a type I choledochal cyst was confirmed and excised laparoscopically. A Roux-en-Y anastomosis was constructed after exteriorization of the small bowel via the infraumbilical trocar incision. A laparoscopic end-to-side hepaticojejunostomy was carried out. The operation lasted 4½ hours, without intraoperative problems. Oral food intake was started on day 2 and well tolerated with bile stained stools. Symptoms of bowel obstruction occurred on day 8. On minilaparotomy, the Roux-en-Y anastomosis was found to be adherent to the mesenterium of the colon, leading to obstruction. After mobilizing the loop, the postoperative course was uneventful. We conclude that laparoscopic resection of congenital choledochal cyst and choledochojejunostomy was feasible in the youngest patient operated on so far. However, adhesive small bowel obstruction can also occur, as after conventional operation, when the bowel is exteriorized for Roux-en-Y hepaticojejunostomy.     

Congenital choledochal cyst and laparoscopic techniques

The authors present a 5-year-old girl with a congenital choledochal cyst and repeated cholangitis. On laparoscopy, a type I choledochal cyst of Todani classification was confirmed. The cyst was excised laparoscopically. After exteriorization of the small bowel through the umbilical incision, a Roux-en Y anastomosis was performed. Then the bowel was reintroduced into the abdominal cavity and a laparoscopic end-to-side hepaticojejunostomy was carried out. There were not intra or post operative problems. Oral food intake started at 72 hours and the patient was discharged on day 5 without complications and with excellent cosmetic results. We conclude that laparoscopic techniques are an excellent option for the resection of congenital choledochal cyst and hepaticojejunostomy in children.     

腹腔镜胆总管囊肿根治切除、肝管空肠吻合术

目的:探讨腹腔镜下胆道造影和胆总管囊肿根治切除、肝管空肠吻合术的可行性。方法:34例先天性胆总管囊肿患者行腹腔镜下胆道造影,胆囊和囊状胆管完全切除,经脐孔提出空肠行Roux-en-Y吻合和体内肝管空肠吻合手术。结果:胆道造影显示胆管囊状扩张24例,梭形扩张10例。33例腹腔镜下顺利完成手术,手术时间平均4.2h(3.5~6.5h);1例胰腺内胆总管远段囊肿中转开腹手术。4例合并肝管狭窄同时行胆管成形术。术后5~7d患者痊愈出院。31例获得随访,5~40个月未发生术后并发症。结论:腹腔镜下胆道造影简便实用,对指导镜下根治切除囊肿,避免损伤胆胰管连接部和处理肝内胆管狭窄有重要参考价值。     

腹腔镜下胆总管囊肿切除、肝管空肠吻合、腹腔外空肠吻合术50例报告

目的探讨腹腔镜下胆总管囊肿根治切除、肝管空肠吻合、腹腔外空肠吻合术的技巧和中期疗效。方法对大的囊肿,于囊肿中部切开前壁,再用电钩横断囊肿后壁;对小的囊肿,围绕囊肿周围游离,完整切除扩张胆管。对反复发生胆管炎症的患儿,采用Lilly’s方法游离囊肿。脐部切口扩大至1.5 cm,将空肠提出腹壁外,行空肠Roux-Y吻合。腹腔镜监视下肝管空肠端侧吻合。结果16例患儿行囊肿全部切除,34例患儿行Lilly’s囊肿切除。1例早期手术患儿术前反复发作胆管炎症,囊肿周围紧密粘连,分离中渗血明显中转开腹完成手术。手术时间190-450 min,平均226 min。8例患儿需要输血。术后住院时间6-16 d,平均8 d。49例术后随访3-39个月,平均26个月。术后并发症4例：1例发生胆漏,经腹腔引流后自愈;急性胰腺炎1例,保守治疗治愈;肠粘连肠梗阻1例,保守治疗;肠坏死1例,开腹探查见空肠肝支肠管梗阻坏死,行肠切除和再次胆肠吻合手术。余45例无腹痛、发热、黄疸等症状。无胆管狭窄和反流性胃炎病例,无手术死亡。结论分离囊肿后壁,避免门静脉损伤是最关键的腹腔镜操作;胆肠吻合是腹腔镜最难的技术。腹腔镜下胆总管囊肿根治术疗效满意。     

腹腔镜下先天性胆总管囊肿切除肝总管空肠Roux-en-Y吻合术

背景Ⅰ型胆总管囊肿的腹腔镜手术治疗由于难度、风险大,少有中心开展。近日我们顺利完成了1例巨大Ⅰ型胆总管囊肿的全腔镜手术治疗。方法采用5孔法,囊肿的显露采用将胆囊与腹壁暂时缝合来完成,用电凝钩顺利完成囊肿的全部分离和切除。肝总管空肠重建方法如下：上提空肠,结肠前距离屈氏韧带25cm处与肝总管行端侧吻合,用4-0的可吸收线连续一层缝合。空肠袢的长度约60cm。结果手术300min,术中出血100ml,未输血。术后5d口服流质饮食,术后7d出院。结论I型胆总管巨大囊肿的全腔镜手术治疗是安全和有效的。     

Laparoscopically assisted extrahepatic cyst excision and left hemihepatectomy for a type IV-A choledochal cyst

Some studies have reported on laparoscopic excision for treating the choledochal cyst, yet there are no reports on laparoscopic surgery for treating type IV-A choledochal cysts that require a liver resection. In this paper, we report on a case of laparoscopic cyst excision combined with left hemihepatectomy and laparoscopy-assisted Roux-en-Y hepaticojejunostomy for treating a type IV-A choledochal cyst. A 51-year-old female was admitted with symptoms of jaundice and cholangitis. Percutaneous transhepatic biliary drainage (PTBD) was done preoperatively for controlling the cholangitis. The imaging studies revealed a type IV-A choledochal cyst with an associated stricture of the left main intrahepatic duct. After the resolution of the cholangitis, total laparoscopic cyst excision and left hemihepatectomy were performed by using the four-port technique, and then a Roux-en-Y hepaticojejunostomy was done by a laparoscopy-assisted method. The total operation time was 420 minutes. The estimated blood loss was 300 mL, and no perioperative transfusion was needed. The tubogram, which was performed through the PTBD on postoperative day 5, showed good patency of the bilioenteric anastomosis and no biliary leakage. The patient was discharged at postoperative day 7 without any complications. This case shows the feasibility of performing laparoscopic surgery for treating a type IV-A choledochal cyst that requires a liver resection. We believe that laparoscopic cyst excision with a liver resection can be one of the treatment options for selected patients with type IV-A choledochal cysts.     

腹腔镜下三种不同胆道重建术在先天性胆总管囊肿治疗中的应用

目的探讨腹腔镜下胆总管囊肿切除后肝管十二指肠吻合术(A组)、肝管空肠Roux－en－Y吻合术(B组)和改良胆肠袢式吻合术(C组)等三种胆道重建术治疗的临床效果和安全性。 方法回顾性分析2012年1月至2016年12月间腹腔镜手术治疗先天性胆总管囊肿的46例临床资料,A组15例、B组17例和C组14例。采用SPSS19.0软件包对数据进行统计描述和分析。术中术后围手术期指标等采用( ±s)描述,组间比较采用单因素方差分析。近期并发症等分类资料采用频数(构成比)描述,组间比较采用Pearson χ²检验。P<0.05为差异有统计学意义。 结果C组的手术时间、术后通气时间、引流管留置时间和术后住院时间均优于A组和B组,差异有统计学意义(P<0.05)。三种术式术后近期并发症发生率差异无统计学意义(P>0.05)。 结论腹腔镜下改良胆肠袢式吻合术与肝管十二指肠吻合术、肝管空肠Roux－en－Y吻合术比较,手术疗效均较理想,同时手术时间更短、术后恢复快、住院时间短等优势,值得临床应用和推广。     

Laparoscopically assisted resection of choledochal cyst and Roux-en-Y reconstruction

Laparoscopic surgery for a congenital choledochal cyst was accomplished in five of eight adult patients for whom it was attempted (63%). Creation of a Roux-en-Y jejunal limb by midline minilaparotomy and hepaticojejunostomy using a laparoscopic sewing instrument facilitated the procedure. Background: Congenital choledochal cyst is a good indication for laparoscopic surgery. However, only two case reports are available at this writing. Methods: Eight adult patients, ages 19 to 61 years (mean, 32.6 years), underwent laparoscopically assisted resection of the choledochal cyst and Roux-en-Y hepaticojejunostomy. Results: The whole procedure was accomplished in five patients (63%). The duration of the procedure ranged from 525 to 680 min (average, 616 min). Open conversion in three patients was necessitated by severance of a small common hepatic duct because of disorientation caused by previous laparoscopic cholecystectomy, electrocautery injury to the common channel distal to the anomalous pancreaticobiliary junction, or heavy adhesion around the cyst secondary to recent severe cholangitis. Creation of a Roux-en-Y jejunal limb by midline minilaparotomy and hepaticojejunostomy using a laparoscopic sewing instrument facilitated the procedure. Conclusions: Laparoscopically assisted resection of the choledochal cyst and hepaticojejunostomy are technically feasible and deserve further clinical trials. apd: 3 April 2001     

复合型胆总管囊肿的腹腔镜手术治疗

目的 总结腹腔镜手术治疗复合型(Ⅳ-A)胆总管囊肿的经验.方法 回顾性分析2002-2009年间腹腔镜手术治疗65例胆总管囊肿患儿的临床资料.其中16例为Ⅳ-A型,切除肝外囊肿及肝门部胆管成形后行肝管空肠扩大吻合术.结果 16例复合型胆总管囊肿均顺利完成腹腔镜手术.8例合并肝总管狭窄,予以狭窄段切开或切除后扩大肝管空肠吻合;4例左右肝管汇合处狭窄,于分叉水平向左右肝管切开行双管-空肠吻合;2例合并右肝管开口隔膜狭窄,经肝门胆管将其切开;2例合并左肝管囊肿下游狭窄,自肝门向左肝管切开扩大成形后行肝管-空肠斜形吻合.2例出现术后并发症,1例暂时性胆漏自愈,1例吻合口狭窄再手术后解除.随访观察肝内囊肿明显减小直至消失.结论 腹腔镜提供的视野放大效果有利于囊肿根治性切除及肝门胆管狭窄矫治.对于复合型胆总管囊肿,腹腔镜肝门部或肝内胆肠吻合安全有效.

Abstract：

Objective To summarize our experience of laparoscopic surgery for complex choledochal cysts (type Ⅳ-A). Methods The clinical data of 65 children of choledochal cyst undergoing laparoscopic choledochal cyst resection were retrospectively reviewed from 2002 to 2009 in our institute.Among those type Ⅳ-A cyst was found in 16 patients. Hepaticojejunostomy was performed using a Roux-en-Y jejunal loop after extrahepatic cyst excision and ductoplasty. Results Laparoscopic procedures were successfully performed in 16 patients with type Ⅳ-A cysts. The stenotic segment was splited or excised and a wide hepaticojejunostomy was completed at the porta hepatis in 8 patients with a stricture extending to the level of common hepatic duct. The constrictive confluence of the bilateral hepatic duct was incised and the bi-ductal cystojejunostomy was achieved at the bifurcation in 4 cases. A septum was found at the orifice of right hepatic duct and was excised through the hilar stoma in 2 cases. A downstream stricture of the left hepatic duct was incised from the hilum to the dilated segment along the lateral wall in 2 patients, so that a long intrahepatic cystojejunostomy was completed in an oblique course. Postoperative complications developed in 2 cases including temporary bile leakage in one case and anastomotic stricture in another. The intrahepatic cysts were remarkably reduced in size during the follow-up. Conclusions With the magnified laparoscopic view, the radical resection of extrahepatic cyst and correction of the intrahepatic bile ductal stenosis can be easily performed. Laparoscopic hepaticojejunostomy and/or intrahepatic cystojejunostomy is effective and safe for children with type Ⅳ-A choledochal cysts.     

Laparoscopic biliary reconstruction

BACKGROUND: Biliary reconstruction represents a relatively untested frontier in laparoscopy. METHODS: Retrospective review of all patients who underwent laparoscopic biliary operations at Legacy Health System from 1998 to 2003. RESULTS: Seven patients underwent laparoscopic biliary reconstruction. Indications included benign calculous disease in 4 patients, benign stricture on 1 patient, choledochal cyst in 1 patient, and malignant biliary obstruction in 1 patient. Operations performed included choledochoduodenostomy, hepaticojejunostomy, stricturoplasty, choledochal cyst excision with hepaticojejunostomy, and cholecystojejunostomy. Median operative time was 300 minutes. Median hospital stay was 4 days. One perioperative complication of a bowel obstruction required reoperation. Median follow-up was 15 months. One patient died of metastatic cancer 8 months after surgery. All other patients are symptom free with no signs of stricture or recurrent biliary obstruction. CONCLUSIONS: Laparoscopic biliary reconstruction represents a viable treatment option in carefully selected patients.     

腹腔镜肝管空肠Roux-en-Y吻合术治疗52例3岁以内婴幼儿先天性胆总管囊肿

目的探讨腹腔镜辅助肝管空肠Roux-en-Y吻合术治疗3岁以内婴幼儿先天性胆总管囊肿的疗效。方法2001年4月～2007年3月,采用腹腔镜技术治疗3岁以内婴幼儿先天性胆总管囊肿52例,其中囊状扩张44例,梭形扩张8例。12例（23%）患儿合并肝门部肝管狭窄,行肝管扩大成形术;采用四孔技术和3～5 mm手术器械完成胆道造影、胆囊和胆总管囊肿壁全层彻底切除;延长脐部切口提出空肠,直视下行Roux—en—Y空肠吻合,然后还纳肠管;经结肠后上提空肠的肝支,镜下将肝管与空肠连续吻合。结果52例在腹腔镜下完成手术,无中转开放手术,平均手术时间226 min（160～455 min）,手术中出血量5～10 ml,无手术中需要输血者。1例肝门胆管狭窄的患儿术后胆漏,持续腹腔引流26 d,自然愈合。术后1～2 d进食,无并发症患儿住院3～6 d。52例术后随访3～72个月,平均32.6月,肝功能正常,无并发胆管狭窄和胆管炎,无结石和胰腺炎发生。结论腹腔镜胆总管囊肿彻底切除肝管空肠Roux—en—Y吻合手术治疗3岁以内婴幼儿先天性胆总管囊肿安全、可靠,镜下放大的手术视野有利于精确的手术操作。     

Laparoscopic hepaticojejunostomy for biliary strictures: the experience of 10 patients

Hepaticojejunostomy is performed to reestablish bilioenteric continuity. During a 5-year period between July 1998 and July 2003, the authors attempted hepaticojejunostomy by a total laparoscopic approach in 10 patients with benign stricture disorders of the extrahepatic biliary tree. Six of these patients had type 1 (extrahepatic, fusiform) choledochal cyst and presented with pain, fever, and jaundice. Four of the patients had iatrogenic biliary strictures after cholecystectomy (2 patients after laparoscopic cholecystectomy and 2 patients after open cholecystectomy). These patients had a variable presentation 1 to 3 weeks after the primary procedure, with peritonitis and/or cholangitis or only progressive jaundice. For nine of the patients (90%), the procedure was completed entirely laparoscopically. The mean operative time was 326.6 min for the patients with choledochal cysts and 268 min for the patients with iatrogenic strictures. One patient with stricture after open cholecystectomy underwent conversion to an open repair because of severe anatomic distortion and fibrosis. Four patients drained bile postoperatively for 5 to 7 days. One patient with iatrogenic biliary stricture after open cholecystectomy required open revision of the anastomosis 18 months after laparoscopic hepaticojejunostomy because of recurrent cholangitis. The remaining eight patients (80%) were doing well a mean follow-up period of 3.1 years (range, 3 months to 5 years). Total laparoscopic hepaticojejunostomy is feasible for a select group of patients, but requires advanced laparoscopic skills, including intracorporeal suturing. It must be attempted only in centers well versed in advanced laparoscopic surgery.     

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 treatment of congenital choledochal cyst

We describe the laparoscopic treatment of a patient presenting with congenital choledochal cyst. Our patient was a 19-year-old man with a complaint of recurrent abdominal pain due to pancreatitis. The choledochal cyst was type I and had a common channel of pancreatobiliary duct, as revealed by endoscopic retrograde cholangiopancreatography. Under laparoscopic guidance, the dilated bile duct and the gallbladder were excised, and a Roux-en-Y anastomosis was constructed with an endo-EEA. Finally, end-to-side anastomosis was carried out by the continuous suture method, aided by an Endostitch between the stump of the hepatic duct and the Roux-en-Y limb. After the operation, slight hyperamylasemia was observed for several days but further treatment was not necessary. Postoperative symptoms were minimal, and the patient was discharged on the 11th day after the procedure. Although it is difficult and time-consuming, laparoscopic operation is highly beneficial for the patient. The use of such instruments as the endostapler and Endostitch may help to simplify this complex intracorporeal procedure involving division and anastomosis of the digestive tract. Received: 7 March 1997/Accepted: 11 April 1997     

Using laparoscopic double hemicircumferential running single-layer suture in hepaticojejunostomy for choledochal cysts in children

Background

To evaluate the feasibility and effectiveness of implementing a double-hemicircumferential running suture in laparoscopic hepaticojejunostomy for choledochal cysts (CDC) in children.

Robotic resection of choledochocele in an adult with intracorporeal hepaticojejunostomy and Roux-en-Y anastomosis: encouraging progress for robotic surgical treatment of biliary disease

Background

Robotic surgery offers three-dimensional visualization and precision of movement that could be of great value to hepatobiliary surgeons. Previous reports of robotic choledochocele resections in adults have detailed extracorporeal jejunojejunostomies. We describe a total robotic excision of a choledochal cyst with hepaticojejunostomy and intracorporeal Roux-en-Y anastomosis.

Methods

A 58-year-old woman underwent a robotic excision of a small choledochocele with hepaticojejunostomy and intracorporeal Roux-en-Y.

Result

Port placement was determined via collaborative surgical discussion and previously reported robotic right hepatectomies. Total operative time was 386 min and total robot working time was 330 min. The hepaticojejunostomy was performed using 5-0 PDS suture with parachute-style back wall and running front wall sutures. The jejunojejunostomy was a stapled anastomosis. Estimated blood loss was less than 100 mL. The patient was ambulating and tolerating oral intake on post-operative day 1, and was discharged home on post-operative day 2.

Conclusions

Robotic resection of choledochal cyst with intracorporeal Roux-en-Y anastomosis is feasible, with advantages over open surgery such as superior visualization, precision, and post-operative patient recovery.     

腹腔镜下胆总管囊肿根治切除及胆道重建术

目的探讨腹腔镜下行胆总管囊肿根治切除及胆道重建术的可行性。方法全身麻醉后腹腔镜辅助下按悬吊肝圆韧带、游离胆囊、术中胆道造影、游离切除囊肿、空肠Roux-Y吻合、肝管空肠吻合、缝合系膜裂孔、放置腹腔引流的步骤完成手术。结果 18例患者腹腔镜下顺利根治切除胆总管囊肿,15例经结肠后、3例经结肠前吻合胆道重建术,手术时间3.5～6.5h,2例术后出现并发症。结论经腹腔镜胆总管囊肿根治切除及胆道重建手术安全可靠,值得临床进一步推广应用。     

Total robot-assisted choledochal cyst excision using da Vinci surgical system in pediatrics: Report of 10 cases

BackgroundThe robotic surgery has been proposed as another adjunct for pediatric minimal surgery for choledochal cyst. However, the Roux-en-Y jejunal limb in most reports on robot-assist choledochal cyst resection is usually created extracorporeally in children. The pediatric surgery team of West China Hospital of Sichuan University had completed 10 cases of total robot-assisted choledochal cyst resection. The aim of this current study was to present our initial experience in total robot-assisted surgery and discuss the technical points.MethodsBetween January 2015 and February 2020, patients with choledochal cysts treated with total robot-assisted procedures were retrospectively analyzed. The data collected included demographic information of all patients, type and size of cyst, operative details and postoperative outcomes.ResultsA total of 10 episodes of patients were enrolled in the study. The median age of the patient was 69.50 months with a mean weight of 20.50 kg. The most common symptoms were abdominal pain, vomiting, and jaundice (60%, 30%, and 30%, respectively). The types of cyst included 2 Ia, 7 Ic and 1 IV. The mean operation time was 218.70 min and there were no red blood cell transfusion and conversion in the 10 patients. The mean time to taking water was 3.37 days and mean time to starting liquid diet was 3.77 days. And the average length of postoperative hospital stay was 7.92 days. All 10 patients were eventually discharged and made uneventful recoveries after the operation.ConclusionsTotal robot-assisted choledochal cyst excision comprising Roux-en-Y limb formation, excision of the cyst and hepaticojejunostomy appears to be safe and feasible in pediatrics. Our initial experience shows that it is recommended to perform total robot-assisted choledochal cyst excision for patients over 4 years while a Roux-en-Y jejunojejunal anastomosis is recommended to be performed extracorporeally by prolapsing the jejunum out of abdominal cavity for patients under 4 years old.Level of evidenceTreatment Study.Type of studyRetrospective Study.     

Management of a ruptured bile duct cyst

A case of a ruptured bile duct cyst in a 25-year-old male patient is presented. The initial management of the clinical presentation of acute abdomen consisted of an exploratory laparotomy and a T-tube cystostomy of a choledochal cyst. Two months later, he was admitted to our surgical department. Preoperative evaluation showed a type IV-A choledochal cyst. The patient underwent excision of the choledochal cyst, cholecystectomy, and the construction of a Roux-en-Y end-to-side hepaticojejunostomy.     

Choledochal cysts in children: a review of 28 years of treatment in a Dutch children's hospital.

OBJECTIVE: To analyse the results of surgical treatment of choledochal cysts. DESIGN: Retrospective study. SETTING: Children's hospital, The Netherlands. PATIENTS: 14 children presenting with choledochal cysts. INTERVENTIONS: Choledochoduodenostomy, Roux-en-Y choledochojejunostomy or Roux-en-Y hepaticojejunostomy. MAIN OUTCOME MEASURES: Morbidity and mortality RESULTS: The mean age of the patients was 20 months (2 weeks to 7 years). 10 patients had a type I choledochal cyst; three a type IV, and one a type V. Mean follow-up period was 6 years (18 months to 16 years). One patient with a type I cyst died of Klebsiella pneumoniae that was resistant to treatment. One patient with a type I cyst treated by choledochojejunostomy had two episodes of cholangitis. Another patient with a type I cyst, treated by choledochoduodenostomy, had one episode of cholangitis. Both could be treated with antibiotics. The other patients had had no complications up to 1997. CONCLUSION: This rare anomaly may lead to severe complications when left untreated or after late treatment. It is easy to manage with low associated morbidity.