Early and Intermediate Outcomes of Laparoscopic Surgery for Choledochal Cysts with 400 Patients

JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 22, Number 6, 2012
ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2012.0018

Early and Intermediate Outcomes of Laparoscopic
Surgery for Choledochal Cysts with 400 Patients
Nguyen Thanh Liem, MD, PhD, Hien Duy Pham, MD, Le Anh Dung, MD,
Tran Ngoc Son, MD, PhD, and Hoan Manh Vu, MD

Abstract

Objective: The aim of this study is to report early and intermediate outcomes of laparoscopic surgery for
choledochal cysts with 400 cases.
Patients and Methods: The operation was performed using four ports. The cystic duct was identified and
divided. The liver was suspended by two stay-sutures: one on the round ligament and the other on the distal
cystic duct. The choledochal cyst was isolated and removed completely, and biliary–digestive continuity was
reestablished by hepaticoduodenostomy (HD) or hepaticojejunostomy (HJ).
Results: From January 2007 to June 2011, 400 patients were operated on. There were 305 girls and 95 boys. Ages
ranged from 1 month to 16 years (mean, 47.5 – 2.1 months). Cystic excision and HD were performed in 238
patients and HJ in 162 patients. The mean operating time was 164.8 – 51 minutes for the HD group and 220 – 60
minutes for the HJ group. Conversion to open surgery was required in 2 patients. There were no perioperative
deaths. Postoperative biliary leakage occurred in 8 patients (2%), resolving spontaneously in 7 and requiring a
second operation in 1 patient. The mean postoperative hospital stay was 6.4 – 0.3 days for the HD group and
6.7 – 0.5 days for the HJ group. Follow-up between 5 months and 57 months postdischarge (mean, 24.2 – 2.7
months) was obtained in 342 patients (85.5%). Cholangitis occurred in 5 patients (1.5%) in the HD group and 1
patient (0.6%) in the HJ group. Gastritis due to bilious reflux was 3.8% in the HD group.
Conclusions: Laparoscopic repair is a safe and effective procedure for choledochal cyst. The rate of cholangitis
and anastomotic stenosis is low.

Introduction

C

holedochal cyst is a rare disease in Europe and the
United States but is a common one in Asia. Cystectomy
and biliodigestive anastomosis have become a standard
treatment for this condition. Laparoscopic operation for choledochal cyst was first introduced by Farello et al.1 in 1995.
Since then, this approach has been used in many centers.2–17
Since 2007, laparoscopic surgery has been routinely used in
our hospital for choledochal cyst.11 The aim of this study is to
present early and intermediate outcomes of laparoscopic
surgery for choledochal cyst with 400 cases.
Patients and Methods
Criteria for inclusion
All children from 1 month to 16 years old with choledochal
cyst of Type I or IVa according to the Todani classification
who underwent laparoscopic repair for choledochal cyst from

January 2007 to June 2011 at the National Hospital of Pediatrics, Hanoi, Vietnam, were included.
Criteria for exclusion
Patients with biliary atresia Type I were excluded. Laparoscopic operation was not indicated for patients with
perforated cyst or previous biliary surgery.
Procedures
From January 2007 to November 2007, cystectomy plus
hepaticoduodenostomy (HD) was carried out. From December 2007 to June 2010, both techniques of HD and hepaticojejunostomy (HJ) were performed. Cystectomies were
performed by one of four senior laparoscopic surgeons. All
biliary–digestive anastomoses were performed by the same
(most experienced) surgeon. The main variables studied were
patient age, cyst diameter, surgical technique, conversion rate,

Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam.

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LIEM ET AL.

operative time, perioperative complications, and follow-up
results.
Surgical techniques
Cystectomy plus HD. The patient was placed in a 30
head-up supine position, with the surgeon standing at the
lower end of the table between the patient’s legs (Fig. 1). A
10-mm trocar was inserted through the umbilicus for the
scope. Three additional 5-mm trocars (or 3-mm for infants)
were placed for instruments: one at the right flank, one at the
left flank, and the fourth 2 cm below the left costal margin.
A carbon dioxide pneumoperitoneum was maintained at a
pressure of 8–12 mm Hg. The liver was suspended from the
abdominal wall by a suture placed at the round ligament. The
cystic artery was isolated, clipped, and divided. The cystic
duct was also isolated, clipped, and divided. A second traction suture was placed at the distal cystic duct and gallbladder
to elevate the liver and to expose the liver hilum (Fig. 2). The
midportion of the cyst was dissected circumferentially. Separation of the left and posterior wall of the cyst from the
hepatic artery and portal vein was meticulously and progressively carried out until a dissecting forceps could be
passed through the space between the posterior wall of the
cyst and the portal vein, going from the left to the right side
(Fig. 3).

The duodenum was retracted downward using an intestinal grasper inserted through the left flank trocar. The lower
part of the cyst was detached from surrounding tissue and
pancreatic tissue using a 3-mm dissecting forceps for dissection and cautery. The distal cyst was removed progressively
and then opened longitudinally to identify the opening of the
choledochus to the common biliopancreatic channel. A small
catheter was inserted into the common channel to irrigate
with normal saline to eliminate debris and biliary stones
(Fig. 4). The distal choledochus was then clipped and divided
(Fig. 5). The upper part of the cyst was further dissected up to
the common hepatic duct and divided under the cystic duct.
The orifices of the common hepatic duct and the right and left
hepatic ducts were inspected internally and identified. The
upper part of the cyst was then divided from the common
hepatic duct 5–10 mm under the hepatic bifurcation. The

FIG. 1. Patient position.

FIG. 2.

Second traction suture.

hepatic ducts were also irrigated via the small catheter to
eliminate debris and biliary stones. The duodenum was mobilized, and an HD was constructed 2 cm from the pylorus
using running sutures (if the diameter of the common hepatic
duct was larger than 1 cm) or with polydioxanone 5/0 interrupted suture (if the diameter was smaller than 1 cm).
A cholecystectomy was then carried out. Different parts of
the cyst were removed through the 10-mm trocar. A subhepatic drain was inserted.
Cystectomy plus HJ. The patient and trocars were positioned the same way as for complete cyst excision plus HD.
The ligament of Treitz was identified by laparoscopy. A 5/0
silk stay-suture was placed 30.0 cm distal to the ligament of

Treitz. A second 5/0 polydioxanone suture was placed 2.0 cm
below the first suture to mark the jejunal limb, which would
later be anastomosed to the hepatic duct. The jejunal segment
with two sutures was grasped with an intestinal grasper. The
trocar at the umbilicus was withdrawn. The transumbilical
vertical incision was extended 1.0 cm above the umbilicus.
The jejunum was exteriorized, and the jejunojejunostomy was

FIG. 3. A dissecting forceps passes through the space between the posterior wall of the cyst and portal vein.


LAPAROSCOPIC OPERATION FOR CHOLEDOCHAL CYST

601
Table 1. Clinical Manifestations (n = 400)
Manifestation
Abdominal pain
Fever
Vomiting
Icterus
Discolored stool
Abdominal tumor
Classic triad

Number

%

352
113

194
99
50
30
9

88.0
28.3
45.8
24.8
12.5
7.5
2.2

Cystectomy plus HD was performed in 238 patients and
cystectomy plus HJ in 162 patients.
Three different techniques of cystectomy were carried out:

FIG. 4. A small catheter is inserted into the common
channel.
carried out extracorporeally. The jejunum was then reintroduced into the abdominal cavity. The extended incision
was closed. The laparoscopic instruments were repositioned,
and the choledochal cyst was dissected and removed. The
Roux limb was brought retrocolic to the porta hepatis. An HJ
was fashioned.
Results
From January 2007 to June 2010, laparoscopic cystectomy
and biliodigestive anastomosis were performed for 400 children with choledochal cysts, including 305 girls and 95 boys.
The patient mean age was 47.5 – 2.1 months (range, 1 month–
192 months). Clinical manifestations on admission are presented in Table 1.

The mean diameter of choledochal cysts on ultrasound was
47.8 mm (range, 10–170 mm). One hundred sixty-three patients had preoperative associated intrahepatic dilatation of
biliary ducts, and 237 had no associated intrahepatic dilatation. Cystic diameter was not different between patients in the
HD and HJ groups (47.5 – 15.4 mm versus 48.3 – 16 mm,
respectively).

FIG. 5. The distal choledochus is clipped and divided.

 Dissection and division of the cyst in the middle before
removing the distal and proximal parts in 249 patients
(62.2%)
 Opening the front wall of the cyst and separating the
cyst from the portal vein while viewing inside and
outside the cyst in 105 patients (26.3%)
 Dissection and division of the cyst from the distal end
before dissecting the middle and upper parts in 46 patients (11.5%)
Perforation of the right hepatic duct occurred in 1 patient
and was laparoscopically closed with 6/0 Vicryl suture
(Ethicon). Transection of two hepatic ducts was done in 3
patients, and ductoplasty was carried out before performing
HD in 2 patients. Laparoscopic HJ at two different sites was
performed in the third patient, in whom the distance between
the two hepatic ducts was too great to bring them together. A
twist of the Roux limb was detected and repaired laparoscopically during operation in 2 patients.
Conversion to open surgery was required in 2 patients
because of a common hepatic duct tear while performing HD
in one patient and because of long operative time in the other
patient with a large and highly adhesive cyst.
Mean operative time was 164.8 – 51 minutes in the HD
group and 212 – 61 minutes in the HJ group. The difference is

significant (P < .01).
Intraoperative transfusion was required in 4 patients.
Postoperative biliary leakage occurred in 8 patients (2.0%):
4 patients in the HD group (1.7%) and 4 patients in the HJ
group (2.5%). The difference is not significant (P = .31). One
patient in the HD group required a second operation. The
leakage resolved with medical treatment in the remaining 7
patients. Subhepatic fluid collection was seen in 2 patients
(0.5%), which resolved after fluid aspiration under ultrasound
guidance.
All biliary leakage and fluid collection occurred before
2009. Pancreatic fistula occurred in 4 patients (1.0%) but resolved with medical treatment. There were no operative or
postoperative deaths.
Postoperative stay was 6.4 – 0.3 days in the HD group and
6.7 – 0.5 days in the HJ group. The difference is not significant
(P = .11).
Follow-up of 5–57 months (mean, 24.2 – 2.7 months) was
obtained for 342 children (85.5%), including 207 patients in
the HD group and 135 patients in the HJ group. Cholangitis
occurred in 5 patients in the HD group. Of these 5 patients, 3
patients required a second operation (2 patients due to


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LIEM ET AL.

anastomotic stricture and 1 patient due to stenosis of the hepatic bifurcation and intrahepatic stones). One patient with
anastomotic stenosis was successfully treated by transcutaneous balloon dilatation. All anastomotic stenoses happened in
patients who underwent their first operation before January

2008.
One patient in the HJ group had cholangitis. The rate of
cholangitis is not significantly different between the two
groups (P = .24). Duodenal bleeding due to ulcer occurred in 1
patient in the HJ group but resolved with medical treatment.
Gastritis owing to bilious reflux occurred in 8 patients in the
HD group (3.8%).

Upper gastrointestinal bleeding due to duodenal ulcer occurred in 1 patient in the HJ group. This complication was also
reported by Martino et al.24
From our results we can conclude that laparoscopic surgery
is a safe approach for choledochal cyst. The postoperative
rates of cholangitis and anastomotic stenosis are low.

Discussion

Disclosure Statement

Results from these 400 laparoscopic operations reveal that
laparoscopic surgery is feasible for choledochal cyst. Only
2 cases (0.05%) required conversion to open surgery. The
laparoscopic operation is indicated for most choledochal cysts
of Todani Type I and Type IVa except patients with previous
biliary surgery or perforated cyst. Our results also demonstrate that laparoscopic surgery is a safe approach for choledocal cysts. The intraoperative complication rate is favorable
in comparison with open surgery.18 All intraoperative complications could be managed laparoscopically.
Twisting of the Roux limb happened in the HJ group. This
complication has also been reported in other series.19 Careful
inspection of the Roux limb before performing the anastomosis could prevent it. A shorter intestinal loop is also recommended to avoid this complication.19
Transection of two hepatic ducts occurred in 3 patients in
our series and has also been reported in other series.6,7 Ductoplasty in a double-barrel fashion could be carried out if the

distance between the two ducts is not too great. HJ in two
different sites is an alternative when two hepatic ducts cannot
be brought together. Internal inspection of the upper remnant
of the cyst to identify the orifice of the common hepatic duct
and right and left hepatic ducts is necessary to avoid this
complication.
The rate of biliary leakage in our series was 2.0% and decreased with operator experience. This complication has not
been seen in our center since 2009.
Postoperative bleeding requiring reoperation did not occur
in any patient, possibly because of improved hemostasis under laparoscopic magnification.
The rate of postoperative complications in our series is
lower in comparison with open surgery.18,20
Follow-up varied from 5 to 57 months, demonstrating that
intermediate outcomes of laparoscopic operations for choledochal cyst are satisfactory. The rate of anastomotic stenosis
in our series was 0.87%. This rate has varied from 9% to 24% in
different reports of results with open surgery.21–23 All patients
with anastomotic stenosis underwent operation between
January 2007 and July 2008. This fact suggests that the rate of
anastomotic stenosis may depend on the surgeon’s skill.
Ascending cholangitis is a great concern in HD. However,
this rate was low in our series and not significant different in
comparison with that in HJ. Gastritis due to bilious reflux was
only seen in the HD group.
We presently perform HD at 3 cm instead of 2 cm from the
pylorus. Whether the rate of reflux would be lower because of
this modification is a question for further research.

Acknowledgments
The authors thank Dr. John Taylor, Clinical Associate
Professor, Department of Pediatrics, School of Medicine,

University of Washington, for his careful reading and valuable comments on the manuscript.

No competing financial interests exist.
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Address correspondence to:
Nguyen Thanh Liem, MD, PhD
Department of Surgery
National Hospital of Pediatrics
18/ 879 La Thanh Road
Dong Da District, Hanoi
Vietnam

E-mail: