Total intracorporeal excision of a choledochal cyst with Roux-en-Y reconstruction in a 10-year-old female patient

This video shows the operative steps of the excision of a congenital choledochal cyst and the subsequent Roux-en-Y reconstruction.

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Total intracorporeal excision of a choledochal cyst with Roux-en-Y reconstruction in a 10-year-old female patient

Authors

Abstract

This video shows the operative steps of the excision of a congenital choledochal cyst and the subsequent Roux-en-Y reconstruction.

Keywords

total intracorporeal excision, choledochal cyst, Roux-en-Y reconstruction, pediatric surgery

Media type

Surgical video

Duration

09'40''

Publication

2008-05

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E-publication

WeBSurg.com, May 2008;8(05).
URL: http://www.websurg.com/doi-vd01en2325.htm

Total intracorporeal excision of a choledochal cyst with Roux-en-Y reconstruction in a 10-year-old female patient

1. Case presentation 00'17''

A ten-year-old female patient presents with a 7-year history of abdominal colic and post-prandial emesis. Her symptoms have been increasing over the last 6 months. On physical examination, she has right upper quadrant tenderness and mild jaundice. Her laboratory values are significant for a total bilirubin of 4.4mg/dL. A CT-scan diagnosed a choledochal cyst and this was confirmed on magnetic resonance cholangiopancreatography (MRCP). In this image from the MRCP, we see an enlarged fusiform choledochal cyst involving the common bile duct. It measures 4.4 x 3.2 x 5.2cm in its dimensions. The patient is positioned supine and is placed in stirrups. The abdominal cavity is accessed and insufflated with a 12mm sub-access device through the umbilicus. Additional 5mm ports are placed in the right and left mid quadrants, and in the upper right quadrant. The primary surgeons operated from between the patient’s legs.

2. Operation commencement with initial dissection of choledochal cyst 01'19''

With the abdominal cavity accessed, the gallbladder is grasped and retracted cephalad. This exposes the choledochal cyst. Under mild traction, the peritoneum overlying the cyst is incised. A combination of sharp, blunt and electrocautery dissection is utilized to expose the cyst. The duodenum is mobilized with a Kocher maneuver to ensure complete excision of the choledochal cyst. In addition to hook cautery, we have found that the Ligasure Force Triad 5 vessel-sealing device can be utilized to further dissect the cyst. The Ligasure device is used as a dissector as is demonstrated here.

3. Dissection and division of cystic duct 02'08''

The cystic duct is identified and carefully dissected from the gallbladder to the dilated common bile duct. When the cystic duct is completely mobilized, it is ligated proximally and distally with a 5mm clip. It is then divided allowing exposure and dissection behind the choledochal cyst.

4. Further dissection of choledochal cyst from portal structures 02'40''

Circumferential dissection is then carried out cephalad toward the bifurcation of the left and right common hepatic ducts. Again, a combination of the hook cautery and Ligasure device is utilized to mobilize the cyst from the adjacent structures. We begin to see the plane between the choledochal cyst and the posterior portal structures. The cyst is further mobilized with the assistance of the Ligasure device. Just below the bifurcation of the right and the left hepatic duct, the common bile duct returns to a normal calibre. It measures less than 10mm when compared with the tips of the scissors. It is then divided at this point.

5. Excision of choledochal cyst 03'38''

With the cyst divided off the common bile duct, traction is placed cephalad on the cyst and further dissection is carried out anteriorly towards the duodenum. Exposure posterior to the cyst is obtained with caudal traction of the cyst. There were dense adhesions due to chronic inflammation. With careful dissection, we had no difficulty dissecting the cyst off the hepatic artery and portal vein. When the choledochal cyst is completely mobilized posterior to its insertion into the duodenum, it is ligated with a series of 2/0 PDS Endoloops. The Endoloop is then divided and the choledochal cyst is excised as demonstrated here.

6. Creation of Roux limb for biliary reconstruction 04'55''

With the choledochal cyst excised, the ligament of Treitz is identified with the aid of a Babcock forceps and blunt grasper. The bowel is then run in preparation for the Roux-en-Y limb. The Ligasure device is utilized to divide the mesentery approximately 20cm distal to the ligament of Treitz. Through the 12mm port, a linear Endo-GIA stapler is introduced and the bowel is divided. The distally divided bowel is then run to a length of approximately 40cm to create the Roux limb to be anastomosed to the common bile duct. We then place 2 Ethibond stay sutures, which are tied to secure the bowel in a side-to-side fashion. Here we demonstrate the placement of a 2nd stay suture. With tension on the stay sutures, enterotomies are then made into the bowel. An Endo-GIA is then placed through these enterotomies to create a side-to-side stapled jejunojejunostomy. The enterotomy where the stapler was introduced is closed with a running suture. Constant tension is placed on the suture by the assistant to ensure a tight closure. The knot is then tied intracorporeally to complete the jejunojejunostomy. The Roux limb is then brought retrocolic through a defect created in the transverse mesocolon. We appreciate a good length with no tension in the preparation for the choledochal jejunostomy. An enterotomy is again made with the hook cautery.

7. Construction of choledochojejunostomy 07'40''

The back wall of the choledochal jejunostomy is created with 4/0 PDS suture in an interrupted fashion. The back wall of the anastomosis is completed with a series of interrupted sutures. Generally, 3 to 4 sutures are needed to complete this back wall. Similarly, the anterior wall is completed with a series of interrupted 4/0 PDS sutures.

8. Closure of mesocolic defect 08'52''

With the choledochal jejunostomy complete, the defect in the mesocolon is closed to prevent an internal hernia.

9. Completion of operation 09'14''

The gallbladder is then removed from the liver bed and a 5mm flat drain is placed adjacent to the choledochal jejunostomy. The gallbladder and choledochal cyst are removed with an Endocatch bag inserted through the 12mm port. The child recovered well and was discharged home on postoperative day 5. She had complete resolution of her symptoms and normalization of her bilirubin levels.