Technical tips concerning laparoscopic hepaticojejunostomy for choledochal cyst in children with a focus on secure anastomosis for small hepatic ducts

Laparoscopic hepaticojejunostomy for choledochal cyst in children is one of the most technically challenging operative procedures. Recent advances in high-definition imaging modalities have brought a better intraperitoneal visibility and expanded the indication to meticulous anastomosis for small bile ducts. In our standardized method, the hepatic duct is resected at the common hepatic duct level above the cyst. The jejunum is then extracted from an umbilical wound, and Roux-en-Y jejuno-jejunostomy is performed. The small hepatic duct is enlarged using a diagonal cut up the left side of the hepatic duct (in the 3 o’clock direction). Anastomotic hole is made at anterior wall of jejunum based on the size of hepatic duct. The mucosa and serosa of the opened hole is approximated using 6-0 monofilament absorbable sutures in order to perform membrane-to-membrane anastomosis. After stay sutures are laid, the posterior wall is sutured using interrupted 6-0 absorbable monofilament intracorporeal knot tying. Anastomosis is completely performed without stent insertion. During the anastomotic steps, the suspension technique for the anterior wall of the hepatic duct is very useful for confirming the lumen of the hepatic duct. However, this approach is associated with several well-known intraoperative pitfalls, such as the involvement of posterior wall needle-driving during anterior wall anastomosis, so the surgical team should be alert to prevent such events.