Laparoscopically assisted extrahepatic bile duct excision with ductoplasty and a widened hepaticojejunostomy for complicated hepatobiliary dilatation.

BACKGROUND: Complicated hepatobiliary dilatation is characterized by congenital cystic dilatation of the biliary tree extending to involve the intrahepatic biliary channels. Some studies have reported on laparoscopic excision for common choledochal cyst, yet there are little reports on laparoscopic surgery for congenital choledochal cyst with intrahepatic bile duct dilatation. In this paper, we present our experiences in laparoscopic extrahepatic bile duct excision combined with ductoplasty and hepaticojejunostomy for complicated hepatobiliary dilatation.

METHODS: We retrospectively studied 153 children (age ranged between 3 months and 12 years) who had undergone laparoscopic cholangiopancreatography and radical choledochal resection in our institute from 2002 to 2012. A co-existing extra- and intra-hepatic dilatation was found in 26 patients. After resecting the extrahepatic dilated duct and widening the portohepatic or intrahepatic ductal lumen (ductoplasty) under the laparoscopic video, a widened hepaticojejunostomy at the hilum was performed using a Roux-en-Y jejunal limb.

RESULTS: Laparoscopic procedures were successfully performed in all children with complicated hepatobiliary dilatation and their ductal stenoses at the hilum were corrected. In 13 patients with a stricture that converged into the common hepatic duct, the stenotic segment was incised and a wide hepaticojejunostomy was completed at the porta hepatis. A constrictive confluence of the right and left hepatic duct was observed in eight cases, a bi-ductal portojejunostomy was achieved at the bifurcation after making incision in the bilateral stenotic hepatic ducts to create a large stoma. A downstream stricture of the left hepatic duct was identified and incised from the hilum to the dilated segment along the lateral wall in three cases, so that a long hepaticojejunostomy to left intrahepatic duct lay in an oblique orientation. In two cases, a septum was found in the right hepatic ductal terminal and excised through the hilar orifice. Postoperative complications were observed in two children including temporary bile leakage and hepaticojejunal anastomotic stricture each one. The intrahepatic duct dilatation was remarkably reduced in size during the follow-up.

CONCLUSIONS: Laparoscopic cholangiopancreatography is a valuable method in offering an accurate delineation of complicated hepatobiliary dilatation associated pancreaticobiliary maljunction and only necessitates simple equipments. With the aid of the magnified laparoscopic view, the radical resection of extrahepatic biliary duct and correction of the portohepatic bile ductal stenosis can be exactly performed. Laparoscopic hepaticojejunostomy at the hilum is effective and safe for children with complicated hepatobiliary dilatation.