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 The gallbladder was retracted superiorly to facilitate exposure of the hilar structures.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