title: Laparoscopic choledochal cyst excision: lessons learned in our experience.
abstract: BACKGROUND
  Choledochal cyst (CDC) is a rare biliary disorder. Surgical treatment consists of CDC excision and biliary-enteric reconstruction. Recently, some institutions have reported successful CDC excision by using minimally invasive techniques. In this study, we report our experience with the laparoscopic management of CDC, with a focus on key operative maneuvers that enhance the likelihood of successful excision.
  
  
  METHODS
  Following institutional review board approval, we performed a retrospective review of patients who underwent the laparoscopic excision of CDC and Roux-en-Y hepaticojejunostomy. Between October 2003 and November 2007, we performed laparoscopic CDC excision in 9 patients (8 female and 1 male). Median age was 4 years (range, 8 months to 16 years). There were 7 type I and 2 type IV cysts, according to Todani's classification. Average cyst size was 4.4 cm (range, 1.3-8.5). The procedures were performed by utilizing four or five trochars.
  
  
  RESULTS
  Six of 9 children presented with preoperative pancreatitis, 1 with abdominal pain, 1 with jaundice, and 1 was found incidentally. Three patients required the conversion to laparotomy due to dense adhesions, secondary to pancreatitis. Six patients underwent successful laparoscopic procedures, 5 had complete cyst excisions, and 1 underwent a proximal excision with distal mucosectomy. Of the 3 patients who required conversion, 2 underwent complete excisions; the other underwent a proximal excision, distal mucosectomy. There were no intraoperative complications. One patient had a postoperative bile leak that required an open hepaticojejunostomy revision. Eight patients had an uneventful recovery. Oral feedings were resumed within an average of 3.4 days (range, 2-9). Average time to discharge was 6.1 days (range, 5-12). Average follow-up time was 18 months (range, 4-48). No further laboratory abnormalities were detected in any of the patients.
  
  
  CONCLUSIONS
  Laparoscopic resection of CDC and Roux-en-Y hepaticojejunostomy in children is an excellent treatment option. Preoperative pancreatitis may cause increased technical difficulty, necessitating a conversion. Proximal excision with distal mucosectomy
authors.affiliation: Department of Pediatric Surgery, Childrens Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California 90027, USA.
authors.forename: Nikunj K
authors.initials: NK
authors.lastname: Chokshi
authors.forename: Yigit S
authors.initials: YS
authors.lastname: Guner
authors.forename: Arturo
authors.initials: A
authors.lastname: Aranda
authors.forename: Cathy E
authors.initials: CE
authors.lastname: Shin
authors.forename: Henri R
authors.initials: HR
authors.lastname: Ford
authors.forename: Nam X
authors.initials: NX
authors.lastname: Nguyen
mesh_terms: D000293:Adolescent; D000713:Anastomosis, Roux-en-Y; D001662:Biliary Tract Surgical Procedures; D002648:Child; D002675:Child, Preschool; D015529:Choledochal Cyst / Q000601:surgery*; D002768:Choledochostomy; D005260:Female; D006801:Humans; D007223:Infant; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D011183:Postoperative Complications; D012189:Retrospective Studies; D016896:Treatment Outcome