Laparoscopic mucosectomy for large choledochal cyst

The laparoscopic excision of the choledochal cyst is feasible, but it entails certain difficulties while dealing with huge cysts because of the risk of injury of important surrounding structures. Mucosectomy of these large cysts is described in open surgery for huge adherent cysts, and the idea can be applied for laparoscopic excision.

Over a period of 5 years, 5 of 30 patients with a large choledochal cyst underwent the laparoscopic mucosectomy. The procedure was done under general anesthesia, with an initial operative cholangiography to delineate the anatomy of the cyst. The common hepatic duct at its junction with the cyst was dissected and cut, leaving the distal end attached to the cystic duct and gallbladder. The cyst was opened at its upper part, and the upper half with the attached gallbladder was excised en block. A plane between the mucosa and the covering of the cyst was found, and the mucosa was peeled by traction and countertraction with proper hemostasis. The procedure was completed by performing hepatico-duodenostomy.

Five patients were operated on by this technique. Their age ranged from 3 months to 8 years. The procedure was done successfully in all patients, but a conversion was needed in 1 patient due to a difficult hepatico-duodenostomy. The operative time ranged from 125 to 180 minutes (mean, 140). The follow-up ranged from 4 months to 5 years, with a relief of symptoms in all cases and with no evidence of cholangitis or jaundice.

Mucosectomy can be performed safely with the laparoscopy. The technique is easy, avoiding the difficult dissection of the huge adherent cyst from the surrounding important structures.