Mei Diao, Professor, Long Li, Professor. Department of Pediatric Surgery, Capital Institute of Pediatrics
Purpose: Conventionally, staged and redo surgeries are thought to be contra-indications for laparoscopy in children with choledochal cysts (CDC) because of adhesions, deranged anatomy, and demanding techniques. The current study is to assess the efficacy of laparoscopic staged and redo surgeries in CDC children.
Methods: Between January 2006 and September 2018, 178 patients were referred to our hospital for the second stage or redo surgeries. Of them, 163 patients successfully underwent laparoscopic definitive surgeries, including 1) staged surgery (n=79), i.e. external biliary drainages before cyst excision and RYHJ for i) CDC perforation with general peritonitis (n=60), and ii) severe inflammation or neonates with huge CDCs (n=19); 2) redo surgeries (n=84): i) revision of choledocho- or cholecysto-jejunostomies (n=4), ii) postoperative bile leak repairs (n=16, 3 of them caused by aberrant hepatic ducts which located in middle portion of cystic duct), iii) postoperative biliary obstructions (n=64). A series of transabdominal retraction sutures were placed through 1) serosa of gallbladder fundus or gallbladder fossa in staged and redo surgeries respectively, 2) proximal common hepatic duct to facilitate dissection and anastomosis, 3) proximal→distal→posterior wall of CDC in staged surgery, 4) hepatic lobe to facilitate anastomosis of aberrant hepatic duct to jejunum.
Results: Conversion rate was 8.4% (15 out of 178 patients), including 1) unclear anatomical structure caused by dense adhesions (n=5), 2) uncontrolled oozing (n=4), 3) stenotic segments extended to the intrahepatic bile ducts, which required extensive dissections (n=4), 4) anastomosis of aberrant hepatic duct to jejunum in early practice (n=2). Of remaining 163 patients, mean age at surgery was 3.5 years. Average operative time was 4.5 hours. Mean postoperative hospital stay, resumption of full diet, and duration of drainage were 6.5 days, 3.1 days, and 4.2 days respectively. Median follow-up period was 45 months. None of patients had biliary re-obstruction, intrahepatic stone formation, cholangitis, pancreatic fluid leak, pancreatitis, wound infection/ dehiscence, or accidental injury of viscera which were directly adherent to the abdominal scar of primary surgery. Two (1.2%) patients with perforated CDCs who underwent staged surgeries developed bile leaks. The bile leaks were caused by unrecognized aberrant hepatic ducts and repaired laparoscopically. Liver function tests were normalized within 1 year.
Conclusions: In experienced hands, laparoscopic staged and redo surgeries is safe and effective in selected CDC children.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95990
Program Number: P241
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster