Totally laparoscopic management in complicated case of choledochal cyst

Hariruk Yodying, MD¹, Sermsri Pongratanakul, MD¹, Vichit Viriyaroj, MD¹, Thammanij Rookkachart, MD¹, Thanatorn Sricharoen, MD². ¹Department of surgery ,Sirindhorn medical center Hospital , Srinakharinwirot University, ²Department of radiology ,Sirindhorn medical center Hospital , Srinakharinwirot University

Background: Choledochal cysts typically are a surgical problem of childhood, but some of the patients can have delay presentation in adult. The adult patients have an increased rate of associated hepatobiliary pathologies and complications which make more challenging in surgical management. We report a total laparoscopic surgery in Type I choledochal cyst with multiple choledocholithiasis and history of previous open abdominal surgery.

Case presentation: A 42-year-old male with a history of recurrent episodes of cholangitis for two years. He underwent open cholecystectomy four years ago. CT scan and subsequent MRCP demonstrated a large type I choledochal cyst with multiple choledocholitiasis. The ERCP and stent were performed with a failed attempt of endoscopic clearance of multiple stones. After the infection was subsided, the patient was scheduled for elective surgery.

Method: He underwent 4 port laparoscopic excision of a choledochal cyst with stones removal and Roux-en-Y hepaticojejunostomy in the following steps. Adhesiolysis was performed to identify a choledochal cyst. The anterior cyst wall was opened. The stones and plastic stent were removed. Choledochoscopy evaluated the evidence of retained ductal stones. Excision of anterior cyst wall and mucosectomy of cyst remnant were performed because of the difficulty of dissection with excessive adhesion between a cyst wall and surrounding tissues. The cyst was transected distally at pancreatic head and proximally at hepatic confluence. The distal biliary stump was closed with interrupted sutures. The bilioenteric flow was reestablished through a Roux-en-Y hepaticojejunostomy.

Result: There was no intraoperative complication. The duration of surgery was 8 hours and intraoperative blood loss was 300 ml. The patient was discharged on postoperative day 4. The pathological examination revealed no evidence of malignancy. He had no relapse of previous symptoms, biliary stricture, recurrent stone or malignancy at his one-year follow-up.

Discussion: The treatment of choice for Type I choledochal cysts in adults is total cystectomy down to the level of communication with the pancreatic duct and Roux-en-Y hepaticojejunostomy. Because of the age-related incidence of cancer, total cyst excision to remove all intracystic epithelium is essential. Some adults have had recurrent infections and prior operations resulting in epithelial degeneration and dense subhepatic adhesions which make more difficult in cyst excision and reconstruction techniques.

Conclusion: Total laparoscopic surgery of Type I choledochal cyst in adults is safe and feasible. This operation technique could be done even in a complicated case and may become the first choice procedure for choledochal cyst.

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Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 84871

Program Number: V090

Presentation Session: Thursday Exhibit Hall Theater (Non CME)

Presentation Type: EHVideo