Successful Laparoscopic Dual Hepaticojejunostomy of the Main Hepatic Duct and the Accessary Duct of the Right Posterior Segment to Successfully Treat a Choledochal Cyst in a 1-Year-old Girl: A Case Report

Background: The first operation for congenital biliary dilation was reported as a cholecystojejunostomy in 1894. Cystojejunostomy was first performed in 1897.1 Bile duct resection has recently become the standard operation because the remnant dilated bile duct is a high-risk location for bile duct cancer.2 Since laparoscopic choledochal cyst resection was first reported by Farello et al.3 in 1995, laparoscopic procedures have been frequently performed, even for pediatric patients. Laparoscopic choledochal cyst resection is a safe feasible treatment for choledochal cysts and is associated with less postoperative morbidity, a shorter hospital stay, and less blood loss than open surgery.4–6 However, hepaticojejunostomy may be technically challenging because of the bile duct size and other anomalies.7 We describe a laparoscopic “dual” hepaticojejunostomy for the hepatic and branch ducts in the right posterior region. Patient and Operative Procedure: A 1-year-old girl presented with intermittent vomiting. Computed tomography (CT) and magnetic resonance cholangiopancreatography showed a 5-cm choledochal cyst with intrahepatic duct dilation. A definitive pancreaticobiliary maljunction (PBMJ) and a bile duct anomaly were not detected preoperatively. Laparoscopic choledochal cyst resection was performed using four ports. Under general anesthesia in a broad base position, a 5-mm 30° laparoscope was inserted through an umbilical incision using the open 5-mm Hasson trocar method. Three additional 5-mm trocars were inserted in the right upper abdomen (operator's left hand), right of the umbilicus (operator's right hand), and left lateral abdomen (assistant). Intraoperative cholangiography showed PBMJ. The common bile duct was connected to an accessory pancreatic duct with an abrupt narrow shape. A 3-mm accessory bile duct from the right posterior region branched independently from the 5-mm main hepatic duct, which was not detected preoperatively. Both ducts were resected at the common hepatic duct level above the cyst to avoid leaving the cystic portion of the hepatic duct. The jejunum was extracted from an umbilical wound and Roux-en Y jejunojejunostomy was performed. The operator's right hand then changed from the port to the right of the umbilicus to the umbilical incision. The laparoscope was inserted through the port to the right of the umbilicus. Bile-duct plasty of the accessary duct was planned for simpler single-lumen anastomosis with the jejunum, but it was impossible to perform because of the long distance. Two small holes (sized for two bile ducts) were made on the antimesenteric side of the jejunum to facilitate dual anastomosis. The mucosa and serosa of the opened holes were approximated using 6-0 absorbable sutures to secure hepaticojejunostomy. The jejunum was pulled up through the retrocolic route. Initially, both posterior walls were approximated by interrupted intracorporeal knot tying. Dual hepaticojejunostomy was completed without stent insertion. Results and Conclusion: The patient was discharged on postoperative day 17 with no postoperative complications. Three years after surgery, CT showed no intrahepatic bile duct dilation or intrahepatic ductal gallstones. The liver function remained normal and ultrasonography showed no intrahepatic ductal dilation. Laparoscopic dual hepaticojejunostomy is challenging, but possible with the recently improved laparoscopic techniques. A careful long-term follow-up is necessary. Acknowledgment: We thank Brian Quinn for his comments and help with the article. No competing financial interests exist. Runtime of video: 5 mins 48 secs