title: Classification of biliary atresia in the laparoscopic era.
abstract: OBJECTIVE
  According to Kasai's classification of biliary atresia (BA), type III is diagnosed when micro bile ducts (MBD) cannot be identified macroscopically on the surface of the biliary remnant transected at the porta hepatis. However, during laparoscopic Kasai (lapKasai), magnification produced by a 30° 10 mm scope at a focal length of 5 cm is ×38 and ×100 when zooming, enabling more MBD to be identified than with the naked eye rendering Kasai's original classification questionable in the laparoscopic era.
  
  
  METHODS
  Intraoperative video recordings of 36 consecutive lapKasai cases (2009-2015) were reviewed to confirm MBD visibility. 85 consecutive open Kasai cases examined macroscopically served as controls.
  
  
  RESULTS
  MBD were not visible under regular laparoscopic magnification during lapKasai in 6/36 (lapMBD-; 16.7 %) cases and visible in 30/36 (83.3 %). However, in open cases, MBD could not be identified macroscopically in 77/85 (macroMBD-; 90.6 %), a typical result reported internationally. For our lapKasai cases, jaundice clearance was lower in lapMBD-cases (4/6 = 66.7 % versus 26/30 = 86.7 %), which was not statistically significant (p = 0.26).  Conversely, survival with the native liver was significantly lower in lapMBD-cases (4/6 = 66.7 % versus 23/30 = 76.7 %) (p < 0.05).
  
  
  CONCLUSIONS
  BA classification may benefit from revision to include laparoscopic findings to categorize BA more comprehensively.
authors.affiliation: Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan. hinakamu@juntendo.ac.jp.
authors.forename: Hiroki
authors.initials: H
authors.lastname: Nakamura
authors.affiliation: Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
authors.forename: Naruhiko
authors.initials: N
authors.lastname: Murase
authors.affiliation: Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Koga
authors.affiliation: Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.|Department of Pediatric Surgery, Hospital Regional de Alta Especialidad Materno Infantil, Monterrey, Mexico.
authors.forename: Joel
authors.initials: J
authors.lastname: Cazares
authors.affiliation: Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
authors.forename: Geoffrey J
authors.initials: GJ
authors.lastname: Lane
authors.affiliation: Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
authors.forename: Hiroo
authors.initials: H
authors.lastname: Uchida
authors.affiliation: Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
authors.forename: Atsuyuki
authors.initials: A
authors.lastname: Yamataka
mesh_terms: D001652:Bile Ducts / Q000601:surgery; D001656:Biliary Atresia / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D010535:Laparoscopy; D008297:Male; D011171:Portoenterostomy, Hepatic; D014741:Video Recording
keywords: Biliary atresia; Classification