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introduction
Choledochal cyst is a biliary malformation characterized by congenital dilation of the common bile duct, more than 84% of cases occur in children under 14 years of age, and the common manifestations are jaundice, abdominal pain, and abdominal mass, and the incidence is higher in Asian populations, which is reported in the literature to be about 1/1000. The overall treatment effect of this disease is good, and laparoscopic adjuvant radical bile duct cyst radical resection has developed rapidly in recent years.
Recently, the pediatric channel of the medical community invited Professor Zhou Chonggao of the Department of Neonatal Surgery of Hunan Children's Hospital to give a lecture on "Whole Process Laparoscopic Surgery for the Treatment of Congenital Choledochal Cyst in Small Infants".
01 Overview
Professor Zhou Chonggao first said that choledochal cyst is a common biliary malformation in pediatric surgery, most of which occur in infancy and childhood, 84% of children under the age of 14, and the ratio of men to women is 1:3, the incidence rate of Asian people is higher than that of Europe and the United States, and the incidence of bile duct cancer is higher than that of the general population.
02 Etiology
Professor Zhou Chonggao pointed out that the causes of common bile duct cyst include the theory of abnormal pancreaticobiliary confluence and the theory of common bile duct weakness and distal obstruction.
- The theory of pancreaticobiliary confluence abnormalities suggests that the bile duct is abnormally connected with the pancreatic duct, and the pancreatic duct joins the common bile duct outside the ampullary ring muscle of Vater, and the common pancreaticobiliary duct is too long, and the pancreatic juice refluxes upward into the bile duct, and the trypsin is activated in the bile, resulting in the destruction of the bile duct wall and secondary dilation.
- The theory of common bile duct weakness and distal obstruction holds that when the biliary tract is weak in the early stages of common bile duct development, the end of the common bile duct is obstructed, bile drainage is poor, and the intrabile pressure increases, resulting in secondary dilation of the proximal common bile duct.
Fig.1 Etiology of choledochal cyst (A: normal confluence of pancreaticobiliary ducts; B: abnormal confluence of pancreaticobiliary ducts)
03 typing
01 Method 1
According to the location, extent, and morphology of bile duct dilation, it is divided into I-V types:
- Type I refers to extrahepatic bile duct dilation, which is the most common, accounting for about 80% to 90%;
- Type II is extrahepatic bile duct diverticulum, which accounts for about 2% to 3%;
- III型是胆总管末段（十二指肠壁内段）的胆管囊肿，约占4%；
- Type IV is simultaneous dilation of both intrahepatic and extrahepatic bile ducts;
- Type V refers to cystic dilation of the intrahepatic bile ducts, often with liver fibrosis. It is now thought to be a separate class of lesions, known as Caroli's disease.
Fig.2 Classification according to the location, extent and morphology of bile duct dilation
02 Method 2
囊肿的横径：纵径>1/3为囊肿型，反之为梭型。
Fig.3 Choledochal cyst cyst (left) and fusiform (right) diagrams
03Simplified typing
04 Characteristics of common bile duct cyst in small infants
Professor Zhou Chonggao said that at present, the diagnosis rate of prenatal ultrasound in small infants with common bile duct cyst is increasing year by year, and it is generally a cyst type. The distal narrowing of the common bile duct and poor bile drainage lead to hepatocellular damage, proliferation of microscopic bile ducts and liver fibrous tissue, liver fibrosis, and even cirrhosis.
Long-term follow-up results in Taiwan and India showed that 9%-17% of choledochal cysts died of liver failure, and domestic studies found that 44.4% of choledochal cysts were combined with common hepatic duct stenosis, which aggravated the formation of intrahepatic bile duct dilation, secondary cholangitis and liver failure. 66.7% of choledochal cysts were born with bile sludge formation, resulting in spontaneous perforation of biliary obstruction.
Fig.4 Diagram of common bile duct cyst complicated by liver damage
05 Age and procedure of surgery
01 Age of surgery
- Children with biliary obstruction should undergo surgery promptly, and guidelines for children without obstruction also recommend surgery within 3 months.
- Surgery after 3-6 months may lead to varying degrees of liver fibrosis, worsening of cirrhosis, and even liver failure.
- The accumulation of experience in neonatal surgery and anesthesiologists, and the age concern of parents are not risk factors for surgery.
02 Surgical method
- External drainage is a transitional surgery, and simple internal drainage has been abandoned;
- Classical surgical methods: cyst gallbladder resection and hepatic duct-jejunal Roux-Y anastomosis are the standard surgeries for radical cure;
- Laparoscopic minimally invasive surgery is a development trend.
06Minimally invasive surgery for choledochal cyst
Professor Zhou Chonggao pointed out that Farello first reported laparoscopic choledochal cyst surgery in 1995, Professor Li Long reported laparoscopic surgery for the first time in 2002, Li Long reported 35 large cases in 2004, and more units of pediatric surgery in China gradually reported after 2010.
Minimally invasive surgical methods include: multi-port/single-port/single-site, 2D laparoscopic/3D laparoscopic/da Vinci robotic surgery, conventional laparoscopic surgery/full laparoscopic surgery.
01 Routine laparoscopic surgery steps
- 建立人工气腹,放置Switch;
- 腹腔镜下胆总管囊肿、胆囊游离切除；
- The jejunum was severed by umbilical transfer and laparotomy surgery, and the jejunum end-to-side anastomosis established a biliary branch intestinal loop;
- The umbilical suture was used to reconstruct the pneumoperitoneum, and the laparoscopic completion of the biliary-intestinal anastomosis was continued.
02Problems with conventional laparoscopic surgery
- Transumbilical transfer and open surgery is required to raise the intestinal tube through the umbilical cord and perform intestinal anastomosis to establish biliary intestinal loops - increasing the surgical steps and prolonging the operation time;
- Increases the risk of intestinal injury and intestinal adhesions;
- Destroy the normal anatomical structure of the umbilical ring, leave scars, and affect the aesthetics of the umbilical cord.
Fig.5 Conventional laparoscopic surgery destroys the normal anatomy of the umbilical ring
03Intraoperative angiography
Preoperative routine MRCP examination to understand the anatomy of choledochal cysts, bile ducts, and intrahepatic bile ducts. If there is any doubt in the preoperative examination, the bile duct development malformation can be detected by cholecystography during the operation, so as to facilitate the timely improvement of the surgical plan and reduce the occurrence of complications.
Fig.6 Intraoperative angiography
04Exchange布局和压力
4-hole Trocar layout scheme: the observation hole lens is inserted from the umbilical or umbilical incision opening, 1 operation hole is located under the costal margin of the right axillary anterior line, 2 operation hole is located next to the rectus abdominis muscle at the level of the flat umbilicus, and the assistant operation hole is located in the left upper quadrant. The observation hole is a 5mm trocar, and the operation hole is a 3mm instrument.
Swipe up to view
Fig.7 Trocar and robotic arm arrangement for radical choledochal cyst
Fig.8 Full laparoscopic surgery step 1: removal of common bile duct cyst
Fig.9 Step 2 of the whole laparoscopic surgery: laparoscopic jejunal dissection
Fig.10 Step 3 of the whole laparoscopic surgery: jejunal end-to-side anastomosis and establishment of gallbladder loop loop
Fig.11 Step 4 of the whole laparoscopic operation: biliary end-to-end anastomosis
Fig.12 Narrowed bile duct splitting
Fig.13 3D laparoscopic surgery
Summary
Professor Zhou Chonggao concluded that it is safe and feasible to undergo full laparoscopic cyst resection and hepato-jejunostomy for congenital common bile duct cyst in infants. Full laparoscopic surgery simplifies the surgical steps, optimizes the surgical process, and shortens the operation time. The biliary-intestinal end-to-end anastomosis surgery has a good field of view, and the intestinal end-to-side anastomosis is difficult, so it should be performed by a physician with rich experience in laparoscopic surgery. Neonatal surgeons who perform asymmetrical sutures have an advantage.
Expert Profile
Zhou Chonggao
- Master, Chief Physician, Director of Neonatal Surgery, Hunan Children's Hospital
- Chairman of Hunan Provincial Congenital Malformation Intervention Professional Committee
- Director of the Editorial Department of the Journal of Clinical Pediatric Surgery
- Member of the Pediatric Endoscopic Surgery Group of the Pediatric Surgery Branch of the Chinese Medical Association
- Vice Chairman of the 3rd Surgical Professional Committee of the Neonatology Branch of the Chinese Medical Doctor Association
- Vice Chairman of the Neonatal Minimally Invasive Group of the Maternal and Child Minimally Invasive Professional Committee of the Chinese Maternal and Child Health Association
- Member of the Pediatric Surgery Group of the Pediatric Expert Committee on Capacity Building and Continuing Education of the National Health Commission
- Member of the Pediatric Surgery Committee of Hunan Medical Association
- Member of the Pediatric Minimally Invasive Surgery Professional Committee of Futang Children's Medical Development Research Center
References:[1] Laparoscopic Surgery Group, Pediatric Surgery Branch, Chinese Medical Association. Guidelines for laparoscopic choledochal cyst surgery (2017 edition) [J] . Chinese Journal of Pediatric Surgery, 2017, 38 (7): 485-494.
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This article reviewed: Professor Zhou Chonggao, Department of Neonatal Surgery, Hunan Children's Hospital
Editor in charge: Xiang Yu
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