title: Totally laparoscopic management of choledochal cyst: Roux-en-Y Jejunojejunostomy and wide hepaticojejunostomy with hilar ductoplasty.
abstract: BACKGROUND
  Cyst excision with hepaticojejunostomy is the treatment of choice for choledochal cyst. However, late complications after definitive surgery develop occasionally, including intrahepatic stones and cholangitis, because of bile stasis resulting from anastomotic stricture, intrahepatic bile duct stricture, and remnants of intrahepatic ductal dilatation. In type IV-A choledochal cysts in particular, biliary stricture is frequently observed around the hepatic hilum, and ductoplasty for stricture is necessary. In this article, we present our experiences with totally laparoscopic surgery comprising excision of the extrahepatic bile duct, Roux-en-Y jejunojejunostomy, and wide hepaticojejunostomy combined with hilar ductoplasty for choledochal cyst.
  
  
  METHODS
  We performed totally laparoscopic surgery on 8 children with choledochal cyst between June 2009 and October 2010. One of them had undergone bile drainage through gallbladder laparoscopically for biliary perforation. Four patients (1 Ic and 3 IV-A cysts) had hepatic duct stricture around the hepatic hilum. Laparoscopic surgery comprising excision of the extrahepatic bile duct and wide Roux-en-Y hepaticojejunostomy with ductoplasty was performed by using four trocars.
  
  
  RESULTS
  The operation was completed laparoscopically for all patients. The mean operation time was 390 minutes (range, 310-460). The mean postoperative stay was 8.4 days (range, 7-14). After surgery, the dilatation of the intrahepatic bile duct was remarkably reduced in size, and all patients are doing well.
  
  
  CONCLUSIONS
  Laparoscopic surgery comprising excision of the extrahepatic bile duct, Roux-en-Y limb formation, and wide hepaticojejunostomy with hilar ductoplasty appears to be feasible for children with choledochal cyst. When there is a stricture near the confluence of the hepatic ducts, laparoscopic ductoplasty appears to be feasible for the surgeon with an advanced laparoscopic skill set.
authors.affiliation: Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan. urushi@sch.pref.shizuoka.jp
authors.forename: Naoto
authors.initials: N
authors.lastname: Urushihara
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Fukuzawa
authors.forename: Koji
authors.initials: K
authors.lastname: Fukumoto
authors.forename: Akihide
authors.initials: A
authors.lastname: Sugiyama
authors.forename: Hideki
authors.initials: H
authors.lastname: Nagae
authors.forename: Kentaro
authors.initials: K
authors.lastname: Watanabe
authors.forename: Maki
authors.initials: M
authors.lastname: Mitsunaga
authors.forename: Hiromu
authors.initials: H
authors.lastname: Miyake
mesh_terms: D000713:Anastomosis, Roux-en-Y; D017734:Bile Ducts, Extrahepatic / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D015529:Choledochal Cyst / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D007582:Jejunostomy / Q000379:methods*; D010535:Laparoscopy; D008297:Male