Case Report Open Access
Laparoscopic Excision of Choledochal Cyst Type I and Roux-En-Y Hepaticojejunostomy: A Case Report with Video Illustration
Antoine El Asmar1*, Charbel Aoun1 and Ziad El Rassi2
1General Surgery Resident, Saint Georges Hospital University Medical Center, Faculty of Medicine, University of Balamand, Beirut, Lebanon
2Associate Professor of Clinical Surgery, General and digestive Surgery-Oncologic Surgery, Saint Georges Hospital University Medical Center, Faculty of Medicine-University of Balamand, Beirut, Lebanon
*Corresponding author: Antoine El Asmar, General Surgery Resident, Saint Georges Hospital University Medical Center, Faculty of Medicine, University of Balamand, Beirut, Lebanon, E-mail: @
Received: April 24, 2017; Accepted: June 7 , 2017; Published: July 10, 2017
Citation: Antoine El Asmar, Ziad El Rassi,Charbel Aoun (2017) Laparoscopic Excision of Choledochal Cyst Type I and Roux-En-Y Hepaticojejunostomy: A Case Report with Video Illustration. Gastroenterol Pancreatol Liver Disord 4(7):1-2. DOI: http://dx.doi. org/10.15226/2374-815X/4/7/001100
Abstract
Choledochal cysts (CDC) are rare congenital anomalies characterized by single or multiple cystic dilatations of the biliary ducts.Total excision of CDC with Roux-en-Y hepaticoenterostomy is the treatment of choice irrespective of age or symptomatology due to its potential malignant transformation.Herein, the technique of laparoscopic choledochal cyst excision and hepaticojejunostomy is presented with an accompanying video.
Introduction
Choledochal cysts (CDC) are rare congenital anomalies characterized by single or multiple cystic dilatations of the biliary ducts. Adults usually present with abdominal pain, infectious complications, or malignancy. Because of the use of imaging, many asymptomatic patients are being diagnosed which comprises around 10-36% of patients with CDC [1]. Total excision of CDC with Roux-en-Y hepaticoenterostomy is the treatment of choice irrespective of age or symptomatology due to its potential malignant transformation. When doing conventional open right subcostal incision, large incisions are appliedin addition to long hospital stay [2]. However, laparoscopic CDC excision has shown good success with minimal complications [3].

Herein, the technique of laparoscopic choledochal cyst excision and hepaticojejunostomy is presented with an accompanying video.
Case Presentation
A 58-year-old male patient presented to our institution with epigastric pain of several months duration. Abdominal ultrasound showedbile duct dilatation. In addition, his liver function tests were disturbed. A CT scan and MRCP showed marked dilation of the common bile duct starting slightly below the biliary confluence proximally, till reaching the pancreatic margins distally. Imaging showed no evidence of tumor. ERCP done showed no evidence of tumor and EUS with FNA revealed a choledochal cyst type I with negative FNA results on histopathological tests. Laparoscopic
excision of the choledochal cyst and Roux-en-Y Hepaticojejunostomy was performed. No intra or postoperative complications were encountered and the patient was discharged home on day 5 after drains removal and feeding.

Performing such a major procedure, in laparoscopic means, allowed for faster patient recovery and discharge, with less morbidity. Such intervention should be performed by a surgeon with expertise in the hepatobiliary field as well as minimally invasive procedures. The video we present shows the main steps in such an operation, along with few tips and guidelines for a safe and complete surgical intervention.
Conclusion
With time, Laparoscopic excision of the choledochal cyst and Roux-en-Y Hepaticojejunostomy should become more popular and adopted by surgeons. Although such a surgical intervention requires advanced laparoscopic skills, the new technologies, devices and laparoscopic instruments will allow an easier process in performance. The associated tremendous decrease in post-operative morbidity as well as hospital stay should drive laparoscopic surgeons to at least attempt this technique before switching to its open counterpart.
ReferencesTop
  1. Ronnekleiv-Kelly, Sean MS, Kevin CE, Aslam P, Timothy M. Management of choledochal cysts. Current opinion in gastroenterology. 2016;32(3):225-231. doi: 10.1097/MOG.0000000000000256
  2. Li Long, Feng W, Jing-Bo F, Qi-Zhi Y, Gang L, Liu-Ming H, et al. Laparoscopic-assisted total cyst excision of choledochal cyst and Rouxen-Y hepatoenterostomy. Journal of pediatric surgery. 2004;39(11):1663-1666.
  3. Bethany J Slater, Steven S Rothenberg. Laparoscopic Treatment of Choledochal Cysts. Springer International Publishing. 2017;581-591.
 
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