Laparoscopic portoenterostomy for uncorrectable biliary atresia using Kasai's original technique

Laparoscopic Kasai portoenterostomy (LKPE) is generally regarded to have a poorer outcome than open Kasai portoenterostomy for the surgical treatment of uncorrectable biliary atresia. We will describe our LKPE as the only center using laparoscopy to perform Kasai portoenterostomy in Japan.

For our LKPE, a 5-mm trocar is placed in the epigastrium in addition to conventional trocar placement. A Ligasure device is inserted through this additional trocar to seal portal vein branches at the porta hepatis draining into the caudate lobe, instead of hook diathermy that is used universally elsewhere because there is an unacceptably high risk for lateral thermal injury to microbile ducts. We minimize porta hepatic microbile duct injury during anastomosis between the Roux-en-Y jejunum and the liver parenchyma around the transected biliary remnant by not suturing where the original right and left bile ducts were present and making sutures deliberately shallow but deep enough to prevent leakage. Our anastomosis is more central to the porta hepatis, like the original Kasai, compared with "extensive lateral dissection" commonly performed elsewhere in Japan. The length of the Roux-en-Y jejunal limb should be individualized, not predetermined to be 30, 40, or 50 cm as is common practice; the jejuno-jejunostomy should fit naturally into the splenic flexure, otherwise the redundant limb may become tortuous as the patient grows, causing bile stasis and possible cholangitis.

Our LKPE can be performed safely and successfully with encouraging outcome.