Total Laparoscopic Excision of Type I Choledochal Cyst with RNY Hepaticojejunostomy

Bestoun H Ahmed, MD, FRCS, FACS, Ziad Awad, MD, Michael Latzko, MD, Michael Nussbaum, MD, FACS, Cynthia Leaphart, MD. UF COM-Jacksonville FL

A 38-year-old female patient presented to the clinic epigastric and Right upper abdominal pain for several years. She was morbidly obese (BMI: 45.2) and H/O HTN, Asthma, GERD and DJD. She had multiple imaging and procedures done. ERCP confirmed the diagnosis. But the stent migrated within 24 hours. MRI/MRCP showed: fusiform dilatation of the common biliary duct likely a type I choledochal cyst with small diverticular outpouching.

The gall bladder is grasped and pushed cephalad to retract the right lobe of the liver. Dissection of the choledochal cyst is performed from surrounding structures in this sequence: anteriorly, medially, laterally, caudad and then cephalad safeguarding the vessels in the lesser omentum and porta hepatis.

The intrapancreatic part of common bile duct is dissected and then transected safeguarding pancreatic duct insertion. The small cyst outpouching is dissected off and removed separately after identification of the common hepatic duct. The Roux Jejunal limb is created and passed in a retrocolic fashion to the right upper quadrant. Hepaticohejunostomy is performed with interrupted absorbable suture material. The specimen is removed and a drain is placed.

The operative time was 250 minutes. She was out of bed same day of the procedure and tolerated oral intake. She was discharged home at postoperative day #2 after removal of her peritoneal drain. She was followed in the clinic with good recovery. Pathology: Cyst with marked acute and chronic inflammation, fibrosis and focal ossification.

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