Transumbilical Laparoendoscopic Single-Site Surgery with Conventional Instruments for Choledochal Cyst in Children: Early Results of 86 Cases

Introduction

Choledochal cyst (ChC) is a common disease in children. The classic treatment for ChC is open surgery with complete excision of the cyst and hepaticointestinal anastomosis. In 1995, Farrelo et al. ¹ performed the first laparoscopic operation for ChC. With the advantages of minimally invasive surgery, the laparoscopic approach for ChC has been gradually adopted in many centers worldwide. Until now, conventional laparoscopic surgery (CLS) using four trocars at separate abdominal skin incisions has become a standard treatment for ChC at numerous centers, including ours.^2–6

For less traumatic surgery and better cosmetic results, the next step of development of minimally invasive surgery is laparoendoscopic single-site surgery (LESS) or single-incision laparoscopic surgery (SILS), in which all laparoscopic trocars are placed at a single site with a single skin incision instead of multiple skin incisions at separate sites as in the CLS. With this technique, there is only one small scar after the operation or none (“scarless”) when the incision is through the umbilicus.^7,8 LESS has been applied successfully for various procedures in children, especially for relatively simple procedures such as appendectomy and cholecystectomy. ⁸ For complex procedures such as surgery for ChC, the use of LESS is still limited. Since 2012 there have been reports on SILS for ChC from only one center.^9,10 In this study, we present our techniques and early results of transumbilical LESS (TULESS) for childhood ChC.

Materials and Methods

Medical records of all patients undergoing TULESS for ChC at our center from September 2012 to December 2013 were reviewed. The choice of performing hepaticoduodenostomy or hepaticojejunostomy depended on surgeon preference. The data regarding the patients' characteristics, clinical presentations, ChC characteristics, operative techniques, and postoperative course were collected and analyzed. All patients were followed up after discharge by a protocol consisting of clinical examination, liver functional tests, and an abdominal ultrasound at intervals of 1 month, 3 months, 6 months, and then annually.

Operative technique

The positions of the patient and the surgical team were the same as those previously reported in CLS for ChC.^3,4 A Z-shaped incision was made on the umbilicus, the periumbilical skin was mobilized from the fascia, and two 5-mm trocars (one long and one short) and one short 3-mm trocar were placed in a triangular fashion within the range of the skin incision (Fig. 1). The conventional 5-mm 30° laparoscope and laparoscopic straight instruments were used in all cases. A transabdominal suspending suture was made to lift the hepatic round ligament to the abdominal wall. A second suspending suture was performed to lift the gallbladder to the abdominal wall on the right. Intraoperative cholangiography was carried out as contrast was injected transabdominally into the gallbladder under direct laparoscopic vision. In the case of a very large and/or tense ChC, the contents of the ChC were aspirated transabdominally through a relatively large canula under laparoscopic control. The cystic artery was cauterized, and the cystic duct was exposed, clipped, and divided. A third suspending suture was made to lift the anterior wall of the ChC to the abdominal wall. The distal half of the ChC was dissected anterior-posteriorly and lateral-medially. More suspending sutures might be needed to facilitate dissection of the ChC distally. The distal narrow end of the ChC was exposed. A 6 French catheter was inserted through the right or left trocar into the distal part of the ChC and irrigated with saline to remove bile sludge or debris. After irrigation, the distal end of the ChC was clipped and transected proximal to the common biliopancreatic channel. The ChC was then dissected proximally to the common hepatic duct and transected above the cystic duct.

OPEN IN VIEWER

FIG. 1.

Placement of trocars.

For hepaticoduodenostomy, the duodenum was mobilized, and the hepaticoduodenal anastomosis was performed 2–3 cm from the pylorus using polydioxanone 5.0 running sutures in one layer. The sutures start with the posterior layer from the left corner at the 3 o'clock position and continue to the right corner at the 9 o'clock position. The anterior layer of the anastomosis was performed in a similar way, from the 3 o'clock position on the left to the 9 o'clock position on the right.

For hepaticojejunostomy, a Roux-en-Y loop was created extracorporeally through the umbilical incision with a length of 40 cm (at a distance of 20 cm from the ligament of Treitz) and was brought back to the abdomen. The Roux-en-Y loop was brought to the hepatic hilum in retrocolic fashion. An end-to-side hepaticojejunostomy was performed in a similar manner to the hepaticoduodenal anastomosis described above.

If the hepatic duct was smaller than 5 mm, a ductoplasty was performed by splitting its anterior wall at the 12 o'clock position in a 4–5-mm length, thus making the size of the hepaticointestinal anastomosis larger at least 8–10 mm.

After the hepaticointestinal anastomosis was performed, the gallbladder was removed from the liver, the abdominal cavity was irrigated, the specimen (the ChC and the gallbladder) was taken out, and the umbilical wound was closed. A subhepatic drain was optional.

Results

For the studied period, 86 patients (64 girls, 22 boys) were identified with a median age of 24.5 months (range, 1 month–11 years). The most common clinical manifestations were abdominal pain (67.4%), vomiting (51.2%), and jaundice (26.7%). The median diameter of ChC was 3 cm (range, 1.5–12 cm). The ChC was successfully excised by TULESS in all cases. Ladd's procedure for associated intestinal malrotation was carried out at the same time in 1 patient. Hepaticoplasty was performed in 12 cases (13.9%) with a hepatic duct diameter of <5 mm. Hepaticojejunostomy was performed in 84 cases (97.7%), versus hepaticoduodenostomy in 2 cases (2.3%). Anastomosis with an aberrant bile duct was performed in 5 patients. Additional trocars were needed in just 1 case (1.2%). There was no conversion to open surgery. An abdominal drain was used in 8 patients (9.3%) in the early period, and no drain was used in the remaining 78 patients (90.7%). The median operative time was 195 minutes (range, 150–450 minutes). However, although the mean operative time of the first 10 cases was 295 minutes, that time decreased to 203 minutes for the next 10 cases (cases 11–20) and to 198 minutes for the remaining cases. There was no anastomotic leakage. Mild umbilical infection was noted in 2 patients (2.3%). The median time from the operation to resuming oral feeding was 3 days (range, 2–4 days).

All patients were discharged in good health with a median postoperative stay of 5 days (range, 3–9 days). At a median follow-up of 10 months (range, 4–18 months), 1 patient (1.2%) from the early period suffered from anastomotic stenosis with cholangitis and needed a redo surgery; all other patients were in good health. The postoperative cosmesis was excellent as the umbilical scar was almost invisible in all patients. All TULESS patients, especially those without an abdominal drain, were virtually scarless (Figs. 2 and 3).

OPEN IN VIEWER

FIG. 2.

Umbilical appearance 3 months after surgery.

OPEN IN VIEWER

FIG. 3.

Umbilical appearance 3 months after surgery.

Discussion

CLS with four separate ports has been a great advancement in management of ChC because of well-known advantages of minimally invasive surgery in comparison with the open surgical approach: it is less traumatic and less painful with faster recovery and better postoperative cosmesis. The safety and efficacy of CLS in management of ChC have been reported to be equal or even superior to those of the open surgery.^5,6 However, all patients undergoing CLS still have some visible scars.

SILS via the umbilicus or TULESS is a new trend in the development of minimally invasive surgery towards “scarless” surgery. ⁷ The umbilicus, originally a natural scar, is used as the single access for laparoscopic procedures, and it can hide the scar after the surgery. However, performing SILS is more difficult than performing CLS because of problems related to triangulation and handling of instruments.^7,8 To facilitate performing SILS, specialized multichannel ports and/or specialized laparoscopic instruments (curve, bent tip, rotating mechanism, etc.) were used in numerous reports on SILS. ⁷ These devices are expensive and add additional costs in comparison with CLS. These issues may explain the limited application of SILS in practice, especially for complex procedures such as surgery for ChC.

Our experience showed that TULESS with conventional straight laparoscopic instruments and without a specialized port was feasible and safe in the management of ChC. Similar results have been reported by Diao et al.^9,10 from Beijing. In our series, there was no conversion to open surgery and no intraoperative complications. Only 1 patient (1.2%) needed additional separate ports (conversion to CLS) for the presence of an aberrant duct, which is challenging even for open surgery. According to our experience, TULESS for ChC presents a technical challenge to the surgeon, and we share the opinion of Diao et al.^9,10 that SILS for ChC should be performed by surgeons with great experience and expertise in CLS for ChC. Apart from the specific problems of SILS such as instrumental clashing and limited triangulation, intracorporeal knotting and suturing with instruments in a nonergonomic position require a good technical skill. Our results showed that the learning curve of TULESS for ChC for experienced surgeons was relatively steep as the operative time after the first 10 cases was significantly decreased and was comparable to that of CLS in our previous reports.^2–5 With accumulation of experience, all 4 subsequent cases with aberrant bile duct were managed successfully by TULESS alone in this series. Other demanding laparoscopic procedures such as hepatic duct plasty and Ladd's procedure for intestinal malrotation were also carried out successfully by TULESS in our series.

Some technical points of our TULESS operation with hepaticojejunostomy for ChC were different from those of the Beijing group. ⁹ The Z-shaped umbilical incision, in our opinion, may have an advantage over the midline incision for creating more space with good cosmesis. Our trocars were placed in a triangular fashion; thus the distances between the trocars could be larger than those placed in a transverse line, and clashing between the instruments could be reduced. In our study, the laparoscope with standard length was used in all cases, whereas a special extralong laparoscope was used by that group. Although these authors have used only 3-mm trocars for instruments, we used one 5-mm operating trocar, which was very useful for 5-mm clip placement and for making the 2.0 transabdominal suspension suture, especially for older children with a thick abdominal wall. A 5-mm suction tube was also better than that of 3 mm in suction of bile sludge and stones. Our results showed that use of one 5-mm operating trocar did not compromise the postoperative cosmesis. During the hepaticojejunal anastomosis, the Beijing group recommended starting the posterior layer from the 6 o'clock position. ⁹ However, we had almost no difficulties in performing sutures of the posterior layer of the hepaticojejunal anastomosis from the 3 o'clock position to the 9 o'clock position.

In our series, hepaticoduodenostomy was performed on 2 patients after excision of ChC. According to our knowledge, these are the first cases of hepaticoduodenostomy performed by TULESS for ChC reported to date. Our previous studies have shown that hepaticoduodenostomy could be a viable option in laparoscopic management of ChC.^2–5 The only concern for this procedure may be the risk of postoperative bile reflux gastritis. Although our 2 patients had no symptoms of gastritis during the follow-up period of 14 and 16 months, longer-term follow-up is still needed.

Early functional outcome after TULESS for ChC was very promising. The time to resume oral feeding after TULESS for ChC was comparable to that after CLS in our previous studies.^2–4 The patients' hospital stay after TULESS in this series was shorter than that in other reports^9,10 and seemed to be reduced in comparison with our previous series of CLS. ⁴ The rate of postoperative complications was comparable to that of CLS.^2–4 The early results of our study supported the reports from the Beijing group that SILS for ChC cyst was comparable to the CLS in term of efficacy but with a better cosmesis.^9,10 Our TULESS procedure for ChC also appeared to be economical because it used fewer laparoscopic trocars and instruments, it did not require any specialized device or additional medications, and it did not increase the operative time and duration of postoperative hospital stay in comparison with CLS.

One of the greatest attributes of TULESS is postoperative cosmetic appearance. ⁷ Our results demonstrated that TULESS for ChC can really be a “scarless” procedure. All our patients had an almost invisible umbilical scar, and their parents were very happy with that. However, our assessment of postoperative cosmesis was still based on the impression of the surgeon and the patient's parents, so further objective and systematic evaluations may be needed.

In conclusion, our initial experience showed TULESS with conventional laparoscopic instruments for ChC in children is feasible, with excellent postoperative cosmesis. The early outcome is promising, and TULESS can be a viable option for scarless surgical management of childhood ChC at experienced centers.