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Oral Presentation - 46
Laparoscopic Surgery for Choledochal Cysts in Children.
N Dessouky*, T Yassin*, KH Bahaaeldin*, A Husein*, S Shehata**
*Cairo University Faculty of Medicine, Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Egypt
**Alexandria University Faculty of Medicine, Department of Pediatric Surgery, Alexandria, Egypt
Background:Cyst excision and biliary reconstruction is the treatment of choice for Choledochal cyst (CC). Laparoscopic approach for treatment of complex biliary diseases has proven to be possible, yet there are only limited reports of using minimally invasive surgery (MIS) in handling this problem in children. In general, few reports have compared Roux en-Y hepaticojejunostomy (RYHJ) and Hepaticoduedenostomy (HDD) for completion of the biliary-enteric (BE) anastomosis after CC excision.
Purpose:to review the different techniques of MIS for the management of Choledochal cyst in the pediatric age group with assessment of the benefits , results and complications of each technique in treatment of such disease in children . These results are compared to those obtained from the classic open surgical approach in correction of such anomaly.
Material and Methods:Thirteen cases with Choledochal cyst (Group-1) were studied and laparoscopicaly managed in the Cairo University Specialized Pediatric Hospital (CUSPH), from June 2007 till September 2010. Eight of them were females and 5 of them were males. Their ages ranged between 1 year and 11 years. The CC was laparoscopicaly dissected and excised with its ligation at the lowest possible level. The proximal end is divided with exposure of the common hepatic duct (CHD) or its confluence. In cases where the CHD larger than 10 mm, a (RYHJ) was performed through an enlarged umbilical port and then end to side anastomosis was completed by laparoscopic hand suturing technique (Group-1A). Cases where the CHD diameter is less than 10 mm, laparoscopic BE reconstruction was performed through a HDD (Group-1B).
The results were primarily compared to those obtained in 10 cases of CC performed during the same period, corrected via the open surgery technique (Group-2).
Results: The Choledochal cyst was type I in 17 cases (73.9%): 5 in each of G-1A and G-1B with 7 in G2, type II in 2 cases (8.7%): a case in G-1B and G2; and type IV in 4 cases (17.4%): 2 cases for each G-1A and G-2. The diameter of CC ranged between 2.3x 2cm minimum & 11x 9.2cm maximum with a mean of 5.1 cm.x3.9 cm. Laparoscopic excision of CC with BE reconstruction was completed in 11 cases (6 in G-1A and 5 in G-1B; in these later, total laparoscopic reconstruction was achieved .Two cases were converted to open surgery: a difficult case of laparoscopic BE anastomosis in G-1A and a case of bleeding from the wall of the CC in G-1B. Bile leakage resulted in 3 cases: 2 in G-1A and a case in G-1B.These have closed spontaneously in all these cases being prolonged for 2 weeks in one case. The mean duration of operation for laparoscopic group was 235 minutes and 172 min in G-1A and G-1B respectively, while the mean duration of operation for open group was 133 minutes .The mean duration of hospitalization was 9 , 7.5 and 11.5 days for G-1A, G-1B and G2 respectively.
Conclusion:Choledochal cysts in children can be effectively and safely managed by MIS. It requires advanced skills and considerable learning curve so as to allow meticulous dissection and suturing in a restricted operative field thus reducing the operative time, hospital stay and possible complications. To reduce reflux, choledocoduedenostomy for small caliber common hepatic duct, apparently is techniqualy easier to be completed laparoscopically with a shorter time for hospital stay. More advanced randomized studies are needed to be able to proper evaluate the results of the different techniques for laparoscopic management of Choledochal cysts in children in comparison to those of the traditional open surgery.