S Velmurugan, HOD of Dept of GI and Lap Surgery, R Archana, MBBS, B Kasi Viswanath, MBBS. Kauvery Hospital, Trichy, Tamilnadu, INDIA
22yr old female presented with epigastric and right upper quadrant abdominal pain. Examination showed mild tenderness in epigastrium and right hypochondrium. There was no palpable mass. Serum amylase and liver enzymes were elevated. Ultrasound abdomen showed grossly dilated common bile duct (CBD). MRCP showed Todani Type I choledochal cyst with multiple secondary calculi in the CBD and acute oedematous pancreatitis with peripancreatic inflammatory changes. Pancreatitis was treated conservatively. She recovered well and she was discharged. 2 months later she underwent total laparoscopic excision of choledochal cyst with Roux-en-Y hepatico-jejunostomy and cholecystectomy. Her postoperative period was uneventful. She was discharged on the 6th postoperative day. The histology confirmed choledochal cyst with no evidence of malignancy. At one year follow up, patient was doing well and her ultrasound and liver function tests were within normal limits.
Surgical Procedure: Veress needle insufflation. 5 ports used. One 10mm, one 10-12mm, three 5mm ports. Calot’s triangle dissected. Cystic artery and cystic duct clipped / ligated and divided individually. Choledochal cyst dissected protecting portal vein and hepatic artery. Distal end of the cyst dissected without injuring the pancreatic duct. Choledochotomy performed. Stones and sludge in the distal end removed. Check choledochoscopy done to ensure complete clearance of stones from the distal end. Distal end divided and suture ligated. Entire choledochal cyst excised leaving a small cuff distal to the hepatic duct confluence. Roux limb of jejunum created with stapler. Jejuno-jejunostomy (side to side) was performed with stapler at 50cm distal to the planned hepatico-jejunostomy site. Biliary limb of jejunum taken retrocolic to porta hepatis. Hepaticojejunostomy done with PDS continuous suture, posterior and anterior layers individually. Mesocolic and mesenteric windows closed. Gallbladder dissected of the liver bed at the end. Drain placed in subhepatic position. Specimen removed using a bag and sent for histology.
Conclusion: Total laparoscopic excision of Type I choledochal cyst with Roux-en-y reconstruction is feasible and safe. It reduces postoperative morbidity and achieves early postoperative recovery.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94577
Program Number: V034
Presentation Session: Exhibit Hall Theater Video Session I
Presentation Type: EHVideo
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