Laparoscopic management of a choledochal cyst in an 8-month-old patient: Roux-en-Y loop performed extracorporeally through the umbilicus (optical port site)

Choledochal cysts are congenital anomalies of the bile ducts. They consist of cystic dilatations of the extrahepatic biliary tree, intrahepatic biliary radicles, or both. This video shows the treatment of a choledochal cyst diagnosed antenatally. This procedure is performed in an 8-month-old girl.

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Laparoscopic management of a choledochal cyst in an 8-month-old patient: Roux-en-Y loop performed extracorporeally through the umbilicus (optical port site)

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Abstract

Choledochal cysts are congenital anomalies of the bile ducts. They consist of cystic dilatations of the extrahepatic biliary tree, intrahepatic biliary radicles, or both. This video shows the treatment of a choledochal cyst diagnosed antenatally. This procedure is performed in an 8-month-old girl.

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contribution

Keywords

Laparoscopic management, choledochal cyst, Roux-en-Y loop, extracorporeally, umbilicus, optical port site

Media type

Surgical video

Duration

04'23''

Publication

2010-03

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E-publication

WeBSurg.com, Mar 2010;10(03).
URL: http://www.websurg.com/doi-vd01en2909.htm

Laparoscopic management of a choledochal cyst in an 8-month-old patient: Roux-en-Y loop performed extracorporeally through the umbilicus (optical port site)

1. Introduction 00'19''

This video shows the treatment of a choledochal cyst diagnosed antenatally. This procedure is performed in an 8-month-old girl.

2. Patient position 00'28''

The infant is placed at the edge of the operating table in a supine position. The surgeon is placed between the patient’s legs and the monitor is at the height of the patient’s head. The scrub nurse is at the operator’s right and the assistant is at the surgeon’s left. A 5mm umbilical trocar is introduced for the 30 degree optic, and two 3mm trocars are placed lateral to the umbilicus, below the umbilical line to be sufficiently away from the operative site.

3. Operative field exposure 00'52''

We begin by identifying the anatomy of the choledochal cyst, of the accessory biliary duct and of the duodenum. To avoid using a liver retractor, we suspend the gallbladder high in the hypochondrium in order to lift the right liver and perfectly expose the operative site. The gallbladder will only be removed at the very end of the procedure. A pledget stitch allows to suspend the gallbladder through the anterior abdominal wall.

4. Choledochal cyst dissection 01'14''

Following an intraoperative cholangiography, we begin the dissection of the choledochal cyst. The best instrument for the dissection here is certainly the monopolar hook. The dissection is performed step by step, avoiding any burns to the duodenum.

5. Common hepatic duct identification 01'28''

The aim here is to reveal the common hepatic duct as quickly as possible, immediately below the junction between the right and left hepatic ducts. We go back down to the duodenum and dissect the choledochal cyst’s distal portion. The common hepatic duct’s division causes a bit of bile to leak in the peritoneal cavity, but allows the choledochal cyst to be easily mobilised.

6. Intrahepatic dissection 02'05''

We complete the intrapancreatic dissection using the monopolar hook.

7. Distal intrapancreatic closure of common bile duct 03'00''

A suture supported by an Endoloop will allow to close the distal intrapancreatic section of the common bile duct.

8. Choledochal cyst ligation and anastomosis 03'08''

The choledochal division is performed with scissors and the choledochal cyst will be ligated here using an Endoloop. In this video, we will not observe the making of the Roux-en-Y loop as it was performed out of the abdomen through the umbilical port site, which barely had to be enlarged for that purpose. The extremity of the mounted loop is identified with a thread to avoid twisting it during its reintroduction in the abdomen and during its transmesocolic passage. Once the transmesocolic opening has been performed conservatively, the mounted loop is brought up to the operative site. A fixation stitch of the common hepatic duct will stabilize the anastomotic zone during the procedure. A transparietal stitch is passed and tied around an extra-abdominal pledget. The opening of the mounted loop is performed with a monopolar hook. Monocryl 6/0 threads are passed through in interrupted stitches. Once the anastomosis has been performed, we can discontinue the liver retraction by performing the cholecystectomy, thus ending the procedure.