Laparoscopic cholangiogram in biliary atresia: a refinement in the gallbladder hitch technique

The study describes a refinement in the gallbladder hitch stitch and assesses the value of the laparoscopic cholangiogram in children with suspected biliary atresia.

Twenty children with neonatal jaundice and no drainage as shown on the HIDA scan underwent a diagnostic laparoscopy through an umbilical 5 mm port. A 3 mm laparoscopic needle holder inserted through a 3.5 mm port to the left of the umbilicus was used to hitch the gallbladder to the abdominal wall. The stylet of a large bore 16F IV cannula then was used to penetrate the gallbladder to perform the laparoscopic cholangiogram.

There was no need for conversion in all 20 children by this technique. Patent biliary anatomy was demonstrated in 11 children (11/20). These children had no further procedures. In 3 (3/20) children, the common bile duct was demonstrated, while the hepatic ducts were not. These children had a laparotomy for Kasai procedure after an open cholangiogram with a vascular bulldog clamp on the CBD confirmed the finding. Six (6/20) had no demonstrable patency; 3 had it confirmed when the abdomen was opened for the Kasai procedure; only those proceeding to Kasai portoenterostomy (3 hepatic duct atresia, 3 complete biliary atresias) had an epidural catheter placed by the anesthetist. The remaining 3 had no further procedure performed due to the advanced nodular liver with ascites and evidence of portal hypertension.

The findings of laparoscopic cholangiogram were confirmed in all six children who underwent laparotomy for Kasai procedure. The laparoscopic cholangiogram using gallbladder hitch reliably demonstrates a patent biliary system (11/11) and was valuable in avoiding further invasive procedures in 70% (14/20) of babies.