Chapter 52. Laparoscopic Biliary Procedures

The most common biliary tract procedure currently performed is the laparoscopic cholecystectomy. This has yielded interest in management of common bile duct (CBD) stones encountered during the procedure. Successful management of such stones during a laparoscopic cholecystectomy is beneficial to the patient by preventing a secondary or more invasive procedure to clear the duct, such as endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic CBD exploration, respectively. Furthermore, an all-inclusive operation may be more cost-effective. Other operations on the biliary tract, including bile duct resections and reconstructions can be the most technically demanding procedures that a general surgeon performs. The advancement of technology and surgical skills in the field of minimally invasive surgery has allowed for traditionally open complex biliary procedures to be attempted and successfully performed laparoscopically. This chapter focuses on minimally invasive techniques in the management of biliary tract disease. Identification and management of CBD stones and performing biliary bypass procedures are discussed in detail. Highly advanced laparoscopic biliary tract procedures that are performed in selected patients are briefly mentioned as well. These procedures have not gained widespread use and are generally performed by specialized laparoscopic surgeons due to the inherent technical difficulties and there are viable endoscopic therapies that are just as effective as the surgical therapies. Nevertheless, the knowledge and utility of these techniques will be important in practices where advanced endoscopic procedures are not available and at centers specialized in hepatobiliary surgery.

Common bile duct stones are present in as much as 10% of patients with cholelithiasis. The large majority of these stones are less than 4 mm and generally pass into the duodenum without any clinical consequence.1 Nevertheless, stones greater than 3–4 mm should be removed since they may cause severe complications such as pancreatitis and/or cholangitis. Cholangiography and ERCP are the standards by which the CBD is evaluated for the presence of stones. Cystic duct cholangiography can be accomplished in 90% of patients and, overall, the intraoperative cholangiogram (IOC) has a sensitivity of 87% and specificity of more than 95% for the detection of stones.2 As it was in the era of open cholecystectomy, the use of IOC during laparoscopic cholecystectomy remains somewhat controversial. Those that support the routine use of IOC cite this practice (1) to clarify anatomy and therefore reduce bile duct injuries during laparoscopic cholecystectomies; and (2) to detect asymptomatic bile duct stones, which may be present in 5–10% of patients undergoing laparoscopic cholecystectomies. The disadvantages of routine IOC are (1) that it prolongs operative time and (2) false-positive results may lead to unnecessary procedures (~50% of patients with incidental CBD stones found at time of surgery will not need any intervention).3,4 Presently, the literature suggests that there is no difference in major and minor bile duct injuries whether routine or selective IOC are performed.2,5–7 Additionally, a large number of routine IOCs have to be performed, compared to a selective approach, to detect missed CBD injuries or retained CBD stones significant in size. Given this, the financial cost to diagnose a clinically significant bile duct stone that was not suspected intra-operatively has been calculated at half a million dollars.7 Therefore, we recommend that surgeons should individually weigh the pros and cons of routine versus selective use of IOC and tailor their practice in that manner. For those who perform IOC in all of their cholecystectomies, they must attempt to do it in all of their cases in order to get the benefits of their approach. And for those who selectively perform IOC should have a predetermined set of criteria to follow in which they feel IOC is indicated in a case-by-case manner (Table 52-1).

There are multiple commercially made cholangiogram catheters and instruments to facilitate IOC. Any type can be used for the procedure described below:

1. Once the cystic duct is identified, the proximal side is clipped as close to the gallbladder as possible. A transverse ductotomy is made just distal to the clip using laparoscopic scissors.

2. A cholangiogram catheter is then inserted via an introducer sheath or fed through a cholangiogram clamp via one of the right upper quadrant ports of a standard laparoscopic cholecystectomy port placement. The catheter is maneuvered into the cystic duct and then is secured with a single clip or held in place with a cholangiogram clamp (Fig. 52-1).

3. Once the catheter is in place, the instruments that may interfere with the cholangiogram imaging are removed. A three-way stopcock is placed on the cholangiogram catheter in order to secure one syringe filled only with sterile normal saline (NS) and another with only the contrast media. The catheter is flushed with NS only to make sure the tip of the catheter is in the correct position in the CBD and all the air bubbles are evacuated from the syringe (since air bubbles in the CBD may look like stones during a cholangiogram).

4. Isotonic contrast media is used for the cholangiogram. We mix it with 1:1 with sterile NS to prepare a 50% solution of contrast media to minimize contrast exposure for the patient and to have an adequate study.

5. The patient is positioned in a slight Trendelenberg position in order to have the contrast opacify the hepatic ducts as well as the distal CBD.

6. Fluoroscopy is used if dynamic imaging is desired. If not, regular static x-ray machine may be used for imaging.

7. Once the setup is complete, contrast is injected while obtaining radiographic imaging. A proper study should document (1) contrast filling of both the right and left hepatic ducts, (2) contrast filling the distal CBD and emptying into the duodenum, and (3) careful evaluation of the CBD for filling defects suggestive of CBD stone(s). If the pancreatic duct is opacified (and visualized) during the injection of contrast, care should be taken to avoid excessive intraductal pressure to minimize the risk of pancreatitis.

Intraoperative ultrasound (IOUS) is commonly used during liver resections to locate liver lesions and its vicinity to nearby hepatic or portal vein. There are laparoscopic ultrasound probes that have also been used for laparoscopic partial liver resections with success.8,9 Its use in CBD evaluation has been more limited, however, prospective trials have shown that IOUS is comparable in terms of sensitivity and specificity to IOC in its ability to diagnose CBD stones.10 This technique involves the use of linear-array transducer with frequency of 7.5–10 MHz. The image is obtained by moving the transducer first along the cystic duct and the hepatoduodenal ligament to the terminal CBD.11,12 Potential advantages of IOUS are that it is inexpensive, noninvasive, and requires a shorter examination time than the more invasive methods. The disadvantages are equipment availability, difficulty in visualizing the distal CBD, and operator dependency. IOUS can be an alternative to IOC for evaluation of CBD stones during a laparoscopic cholecystectomy in experienced hands (see also Chap. 49).

Choledocholithiasis is defined as the presence of stones in the CBD. The most common location of obstruction is at the papilla, which is the most narrow portion of the duct. There are several preoperative findings on laboratory tests and radiographic imaging as well as intra-operative findings that can predict the presence of CBD stones (Table 52-2). The management of CBD stones differs depending on (1) whether they were found preoperatively or intra-operatively, (2) the experience of the surgeon performing laparoscopic or open CBD exploration, and (3) the availability of ERCP in your practice (Fig. 52-2).

In general, patients who are diagnosed with CBD stones prior to their cholecystectomy are usually symptomatic from their CBD stones—they may present with jaundice, cholangitis, and/or pancreatitis. The management differs significantly depending on the surgeon's ability to perform laparoscopic CBD exploration and the availability of ERCP in the institution. For instance, if the surgeon cannot perform a laparoscopic CBD exploration and ERCP is not available, the options are to (1) perform an open cholecystectomy and CBD exploration, especially if the patient is unstable for transfer, or (2) transfer the patient to a facility where at least ERCP is available. Conversely, if the surgeon can perform a laparoscopic CBD exploration and ERCP is available at that institution, any treatment strategy will suffice (Fig. 52-2A).

The reported success rate of ERCP for clearing the CBD of stones approaches 90–95%, although this varies with the local expertise and experience of the endoscopist. Stone size is the limiting factor with stones greater than or equal to 2 cm will require fragmentation prior to removal. A sphincterotomy is usually performed because relying on spontaneous stone passage increases the risk of pancreatitis, stone impaction, and/or cholangitis. The laparoscopic success rate of clearing the duct is 70–90%. The choice of clearance method should be based on several factors: (1) the availability of expert endoscopists with high success rate with ERCP and stone extraction, (2) the availability of laparoscopic and choledochoscopic equipment, (3) the surgical expertise in laparoscopic CBD surgery, and (4) the general condition of the patient. Table 52-2 suggests a strategy for selective use of preoperative ERCP.

In contrast to those who are diagnosed with choledocholithiasis preoperatively, CBD stones found at the time of surgery are usually incidental findings after an IOC. These patients have normal preoperative radiographic imaging and liver function tests. The algorithm in this setting is relatively straightforward (Fig. 52-2B). In one study, only half of the patients with a positive IOC finding required postoperative ERCP.3 There is a significant false-positive rate with IOCs and in cases where there really is a CBD stone, there is a good chance that it will pass spontaneously if it is smaller than 5 mm in size. However, patients should have a postoperative ERCP to remove the CBD stones if the stones are larger than 5 mm in size. If one chooses to observe the small CBD stones, ERCP may be performed at a later time if the patient develops symptoms and/or elevated liver function tests.4,13–15

When a CBD stone is found during an IOC, several treatment options are available. If the duct is small and a single, less than 5 mm stone is found, a simple maneuver may be attempted with just the cholangiogram catheter still in the CBD. Intravenous (IV) administration of 1–2 mg of glucagon followed by the flushing of the CBD with saline is sometimes successful in clearing the duct (Fig. 52-3). Larger stones or the presence of multiple stones will require other methods of clearance. Laparoscopic transcystic duct exploration without a choledochoscope will be described first. This can be accomplished with a balloon or a basket technique.

Balloon Techniques

Low-pressure balloon catheters may be introduced through a percutaneous cholangiogram sleeve into the cystic duct and then into the CBD. A 4 French (4F) Fogarty-type balloon catheter is most effective and can fit through a 12–14F introducer sheath placed in the abdominal wall.16 Once the catheter tip is in the duodenum, correct position of the catheter tip should be confirmed with radiography to avoid disruption of the ampulla by direct dilation. The balloon is then inflated and gently pulled back typically causing the duodenum to move with movement of the catheter. Traction is stopped and the balloon deflated. The catheter is withdrawn approximately 1 cm and the balloon is reinflated. Traction is then resumed until the balloon is seen at the cystic duct cannulation site. Occasionally small stones or debris can be delivered by this method (Fig. 52-4).

Another option is to use balloon dilation of the ampulla/sphincter of Oddi. Results from a few series have shown it to be a useful complementary tool for clearing CBD debris at the initial operation without embarking on the more complex CBD exploration via a formal choledochotomy. The technique employs a 6-mm diameter balloon dilating catheter over a guide wire. This is most easily accomplished using the right subcostal port site in the standard laparoscopic cholecystectomy or, alternatively, using an additional trocar in the right subcostal space. Fluoroscopy is used throughout the procedure. The wire is confirmed to be in the CBD and the distal tip in the lumen of the duodenum. The balloon catheter is advanced over the wire and passed through the ampulla and into the duodenum. The balloon is then inflated using a dilute contrast media. The location of the ampulla is demonstrated by the point at which the inflated balloon catheter cannot be withdrawn out of the duodenum and into the biliary system. Radiopaque markers on the balloon catheter help guide the deflated catheter so that it traverses the sphincter of Oddi. The balloon is then slowly inflated. The balloon should never be inflated larger than the diameter of the CBD. Dilation is held for a few minutes and then deflated. This is followed by irrigation of warm saline through the cystic duct and a complete cholangiogram. Placement of a drain is usually not necessary. Instrumentation of the ampulla may result in pancreatitis and this should be kept in mind in the postoperative period. The incidence of pancreatitis is less than 10% unless the sphincter is forcefully disrupted. Operative time is usually less than 2 hours when accompanied with a cholecystectomy with successful clearance of stones reported 85–93% of the time.17,18

Basket Techniques

Stone retrieval baskets may also be introduced through a 12–14F introducer sheath. Either a helical (Dormia-type) or straight (Segura-type) basket may be employed. While some authors advocate using baskets with soft filiform tips in order to avoid damage to the duct, there appears to be no difference in ductal injuries as compared to nonfiliform-type baskets.19 However, it is important to use these baskets with extreme care. These baskets can be employed with or without fluoroscopy. When using the basket with fluoroscopy, the duct is filled with contrast media though the cholangiogram catheter that is already in place and the location of the stone is determined. The basket is then inserted through the introducer sheath into the duct and manipulated with the forceps. The position of the basket and the stones are monitored with fluoroscopy (Fig. 52-5). There are two disadvantages with this technique: (1) the radiation exposure to the operating team and (2) the difficulty in manipulating the basket with the fluoroscopic C-arm in position over the patient. Because of these disadvantages, many have described using a nonfluoroscopic technique.20 In order to accomplish this, several factors must be established. First, the surgeon must know the approximate length and course of the cystic duct as determined by the cholangiography. Second, the basket needs to be calibrated lengthwise in order to know the location of the tip of the catheter. Lastly, the surgeon must control the handle of the basket to know when the basket is open, closed, or partially closed suggesting the capture of a stone. When the basket is placed in the distal duct, the basket is gradually closed as it is withdrawn. This maneuver may have to be repeated several times. A major complication is capture of the papilla if the basket is advanced too far into the duct. This requires careful manipulation as pancreatitis or duct perforation may easily occur.

The CBD can be explored under direct visualization if a choledochoscope is available. Before the CBD is cannulated with the choledochoscope, the cystic duct must be prepared. The procedure is performed at the time of laparoscopy after the cholangiogram. In order to pass the scope easily and safely, the cystic duct must be large enough for this approach.16,20,21 When the cystic duct is small, attempts to dilate it may be useful. Cystic duct dilation may be safely done up to 4 mm but not beyond 8 mm because of the increased risk of disruption.20 Dilation may be performed by mechanical tapered dilators or balloon dilation. Although the most expensive way is pneumatic dilation, this is felt to be safer since radial dilatational forces exerted on the duct are safer than the shearing force of gradual mechanical dilation. The balloon-tipped catheter is passed over a 0.035-in hydrophilic wire and dilated to approximately 6 mm (Cook, Bloomington, IN). In the situation that the cystic is very short and large enough to accept a choledochoscope, curved-tipped forceps may be inserted to expand the duct. If the cystic duct–CBD junction is disrupted by forceful dilation, an open repair may be required. Once the cystic duct is dilated, the scope is inserted using the hydrophilic guide wire already in place through a sheath placed as close to the cystic duct as possible. Alternatively, the scope may be introduced without a guide wire as well (Fig. 52-6). Careful manipulation of the scope with atraumatic forceps is extremely important as these scopes can easily be damaged. The scope can be advanced over a guide wire or freely into the cystic duct with manipulation using grasping atraumatic forceps. The most difficult part of accessing the CBD is negotiating the scope through the cystic duct. In this situation, the gallbladder should be retracted as to straighten the cystic duct as much as possible and the choledochoscope angle should be straightened as much as possible. The scope is then advanced via the cystic duct into the CBD under direct vision. The scope is first directed into the distal CBD and stone(s) visualized may be removed with a basket passed via the working channel of the scope. Once the stone is negotiated into the basket, both the scope and the basket are removed together through the cystic duct.

A complete cholangiogram should be performed to document clearance of both the common and hepatic ducts. Because the cystic duct has been dilated, it is best secured with a suture ligature rather than placing metal clips. Inspecting the proximal ductal system is rarely possible since it requires a short cystic duct entering at a 90-degree angle; however, proximal exploration is rarely needed. In this case, the laparoscopic surgeon can attempt to clear the duct via a direct choledochotomy approach.

While a transcystic approach clears the duct in the majority of cases, in certain instances it will not be feasible or successful. The lumen of the duct may not dilate enough to accommodate a scope or the duct may follow a long tortuous course before joining the CBD. In this situation, the surgeon has the option of performing a postoperative ERCP or transductal exploration either via open or laparoscopic approaches. We will describe the laparoscopic approach. We do not recommend this approach in patients with small CBDs (<6 mm). A transductal exploration allows the surgeon to easily explore the proximal and distal ductal system, use a larger scope, and evacuate the stones directly. A choledochotomy will require the placement of a T-tube, which has the advantage of potentially retrieving stones in the postoperative period.

The gallbladder is left in place to facilitate upward and cephalad retraction to straighten and provide tension to the common duct. Just distal to the cystic duct–CBD junction, a short, anterior longitudinal ductotomy is created sharply. It is important to avoid vigorous circumferential dissection around the duct and use a longitudinal incision along the axis of the duct to prevent subsequent development of ischemic strictures by inadvertent injury to the CBD blood supply. The choledochoscope is introduced at a right angle to the common duct and advanced under pressure saline irrigation, allowing the CBD to nicely distend and visualize any stones or strictures. The scope can also be advanced proximally to remove stones with baskets or balloon as previously described.

Upon completion of the laparoscopic CBD exploration via the choledochotomy, T-tube closure of the common duct is recommended. An appropriate size T-tube is selected based on the size of the duct, usually a 12–14 Fr T-tube is sufficient. The tube is fashioned to the surgeon's preference. Filleted tubes are easier to insert. A long and short segment allow for orientation when inserted into the peritoneum and then again when inserted in the bile duct. Also, the point of entry in the abdomen to the point of entry into the duct should follow a smooth curvilinear route. The standard trocar sites do not usually allow for this and as such a separate stab incision should be used when the tube is brought out. The T-tube is fully inserted into the abdomen, the horizontal limbs are compressed with a grasper and inserted into the CBD. The choledochotomy is then closed over the long end of the T-tube, beginning at the neck and working caudally using interrupted 4-0 absorbable suture. Intracorporeal suturing is used to accomplish this (Fig. 52-7). The tube is then brought out lateral to the CBD and out of the abdomen at a suitable location keeping to the principles highlighted above. A complete cholangiogram is recommended to ensure correct tube placement. A subhepatic closed suction drainage is then inserted and removed if there is no bile leakage around the T-tube.

Laparoscopic biliary tract resection and reconstruction is not currently widely applied because it is technically challenging even in an open setting. In addition, there are alternatives to surgery such as endoscopic placement of biliary stents or percutaneous placements of transhepatic biliary drains for biliary obstruction. Nonetheless, laparoscopic cholecystojejunostomy, choledochoduodenostomy, hepaticojejunostomy, and choledochal cyst excision have been successfully performed in the hands of experienced laparoscopic surgeons.22–27 Surgical biliary bypass to relieve malignant obstructive jaundice requires the morbidity of an operation whether it is minimally invasive or open. While minimally invasive surgery allows for less postoperative pain and more expedient recovery, the inherent risks of general anesthesia and surgical stress remain. In light of this, endoscopic stenting has gained utility especially in the palliative setting. The success of endoscopic techniques, such as stenting and sphincterotomy, in the management of malignant biliary obstruction is well documented.28 However, recurrent jaundice and cholangitis from stent obstruction or migration necessitate changing of the stents and add to the overall morbidity and cost. Newer, self-expanding metallic wall stents have had less frequent rates of occlusion.29 Nonetheless, patients who are younger, healthier, who might have increased survival (>6 months) or for those whom endoscopic biliary stenting is not technically possible, will be better served by a surgical biliary bypass. For benign disease, endoscopic management is not indicated as it does not achieve the long-term patency that is desirable for the treatment of benign disease. Thus, surgical biliary bypass will continue to be a valid treatment option.

While the enthusiasm for laparoscopy has extended to complex biliary procedures, it is important to keep in mind that indications and patient selection for biliary bypass do not change with the laparoscopic modality. In fact, the technical considerations often limit rather than broaden the patient selection. Furthermore, fundamental laparoscopic principles that contraindicate its use or require discontinuation and conversion to an open procedure should always be kept in mind. It should also be emphasized that standard, accepted procedures should not have to be significantly modified to make them easier to perform in the laparoscopic setting. Conversion to an open procedure should be utilized if the goals of the operation cannot be accomplished safely through the laparoscopic technique.

Laparoscopic Cholecystojejunostomy

Laparoscopic cholecystojejunostomy is a safe, effective method of palliation for biliary obstruction.1 It is relatively easy to perform when keeping with standard laparoscopic principles and can be accomplished in 45–60 minutes.1,30 In patients with prior surgery and small bowel adhesions, adhesiolysis may be required to ensure that there is no tension or twisting of the bowel loop that will be utilized in the anastomosis. It should also be noted that postoperative episodes of cholangitis are more frequent with cholecystoenteric bypass when compared to other biliary-enteric bypasses.31 Despite the limitations, it continues to be worthwhile in select patients.

In all instances, cholangiography, either intraoperatively or preoperatively via ERCP, should be performed to confirm the patency of the cystic duct and hepatocystic junction. This step is imperative since obstruction of either the cystic duct or hepatocystic junction will result in failure of the operation with recurrent biliary obstruction. Tumor encroachment within 1 cm of the hepatocystic junction is also a contraindication for cholecystojejunostomy. Table 52-3 lists the relative and absolute contraindications for a laparoscopic cholecystojejunostomy. A retrospective review of 218 patients from our institution revealed that only about 20% of patients that are candidates for a laparoscopic cholecystojejunostomy actually remain eligible after further testing.22,32 Thus, this procedure is indicated for only a minority of patients. The relative ease with which it can be performed and the palliative function that is provided without the associated morbidities of an open operation make it a valuable option in carefully selected patients.

The patient is placed supine and general endotracheal anesthesia is induced. See Fig. 52-8 for the location of the port placement.

1. Confirm the patency of the cystic duct if it has not been done by ERCP preoperatively. This can be accomplished by grasping the gallbladder and needle decompressing until it is at least half-emptied. The gallbladder is then cannulated and contrast injected under fluoroscopy. The procedure should not commence if the cystic duct is occluded or if the hepatocystic duct junction is strictured from tumor involvement.

2. Next, a suitable loop of small bowel is grasped using atraumatic graspers and the small bowel is run 30–40 cm distal to the ligament of Treitz. This segment of small bowel is transposed to the right upper quadrant (antecolic) and placed adjacent to the fundus of the gallbladder in a parallel orientation (Fig. 52-9A). Sometimes the body habitus or positioning makes alignment of the bowel and gallbladder difficult. In these circumstances, the setup for this anastomosis may be facilitated by passing a 3-0 nylon suture on a Keith needle through a separate stab incision in the right upper quadrant. The needle is expeditiously grasped once inside the peritoneal cavity to prevent inadvertent visceral injury. The needle is then passed through the gallbladder and then the anti-mesenteric side of the jejunum. The needle is then passed back out of the peritoneal cavity and secured extracorporeally. This suture will help manipulate the bowel and gallbladder during stapling.

3. An enterotomy and cholecystotomy are then made in the bowel and the gallbladder, respectively, using the hook-cautery device passed through the right upper quadrant 11-mm port (Fig. 52-9B). The opening should be as small as possible and a grasper can then be used to enlarge the track to permit the end of the laparoscopic stapling device to be placed through without difficulty. Confirmation of intraluminal penetrance is confirmed by placing a grasper through the enterotomy and visualizing mucosa.

4. The enterotomies are then held in apposition using the left-sided ports. Once these left-sided graspers have been placed, they should not be moved until the stapler is fired. We use a Endo GIA-30 2.5 mm laparoscopic stapler (Covidien, Norwalk, CT) for our anastomosis. The stapler is placed through the right upper quadrant 12-mm port. One blade of the stapler is inserted in the cholecystotomy. The enterotomy is then pulled over the second (lower) blade. The stapler is carefully closed making sure that no small bowel mesentery or adjacent structures have been caught. The stapler is fired and removed (Fig. 52-9C).

5. The graspers are then used to open the anastomosis to permit inspection of the staple line for integrity and hemostasis (Fig. 52-9D). Clips may be utilized for hemostasis.

6. The enterocholecystostomy is closed by transverse stapling of the anastomotic site taking care not to narrow the cholecystojejunostomy. This usually requires sequential firing of at least two Endo GIA staplers.

7. Finally, the stay suture is removed and the anastomosis is inspected. Placement of a drain is not necessary.

A completely hand-sewn anastomosis can also be performed. The operative time for this is usually significantly greater and the patency and complication rates are not significantly different.26,32 Hence, our bias is to perform the faster stapled anastomosis. Another variant is to staple the anastomosis between the bowel and gallbladder and then close the enterocholecystostomy with a running intracorporeal stitch using 3-0 absorbable suture. This may be useful in instances in which the stapler cannot be configured to prevent narrowing of the newly created anastomosis during closure of the defect. Another variant is to a use a Roux-en-Y reconstruction rather than a loop reconstruction.

Laparoscopic Choledochoduodenostomy and Hepaticojejunostomy

The gold standard for open biliary bypass is choledochoduodenostomy or the more commonly utilized Roux-en-Y hepaticojejunostomy. As stated previously, many patients are ineligible for the cholecystojejunostomy. In an effort to increase the number of patients qualifying for laparoscopic biliary bypass, laparoscopic choledochoduodenostomy and hepaticojejunostomy have been investigated and successfully performed. Furthermore, these two procedures are preferred over cholecystojejunostomy in patients with benign diseases such as choledocholithiasis, inflammatory strictures, or iatrogenic bile duct injuries since they have a better long-term patency rate. These procedures are considered highly advanced laparoscopic procedures and take a significant amount of time to perform. Median operative time in the hands of a skilled minimally invasive surgeon is 300 minutes compared to the open median time of 180 minutes.26,33–35 Advancements in surgical technology have aided surgeons to reduce the operative time. Lapra-TY (Ethicon), Surgitie (Covidien), and Endo-Stitch (Covidien) facilitate intracorporeal suturing. The temporarily endoluminally stented anastomosis (TESA) technology has been used in animal models to assist in anastomosis creation.27,35 The basic principles remain the same, but certain variances have been adopted for successful laparoscopic performance. For instance, a transverse choledochotomy rather than the traditional longitudinal has been used for a laparoscopic choledochoduodenostomy. If a transverse choledochotomy is made, care must be taken to avoid devascularizing the bile duct as the blood supply runs parallel to the duct at the lateral and medial aspects of the duct. For a choledochoduodenostomy, the duodenum is longitudinally incised following a Kocher maneuver and a side-to-side anastomosis is created using a 4-0 polyglycolic acid suture (Fig. 52-10). Roux-en-Y hepaticojejunostomy are beginning to be performed at a few centers with a moderate amount of success being reported.33–35 In one series of 14 patients who underwent laparoscopic hepaticojejunostomy, the median operative time was 129 minutes. However, the median hospital stay was 9 days.36 Further studies are needed to determine the value of these more complex biliary bypasses.

Laparoscopic Choledochal Cyst Excision

Choledochal cyst is a congenital disease which results in dilatation of the intra- and/or extrahepatic biliary tract. This condition is rare in the United States (incidence 1:100,000–2,000,000 live birth), but is more prevalent in Asia. The etiology of the disease is unknown. Most patients are diagnosed during their first year of life, but the diagnosis may be delayed into their adulthood since it may not cause any symptoms until then. Common signs or symptoms are right upper quadrant pain or mass, jaundice, and/or cholangitis. Even if they are asymptomatic, treatment is indicated because it carries a 9–28% lifetime risk of malignant degeneration into cholangiocarcinoma and the cyst may be harboring cancer at the time of diagnosis. There are five types of choledochal cysts and their surgical treatment differs based on their anatomic differences (Table 52-4). Type I is the most common type and these can be treated with a CBD excision of the involved segment. Reconstruction is performed with a Roux-en-Y hepaticojejunostomy and excellent long-term results can be achieved. Excision of the CBD does not eliminate the risk of malignant degeneration since the entire biliary tree is at risk. Thus, some hepatobiliary surgeons leave a small cuff of dilated bile duct on the proximal (liver) side so it would be easier to sew the hepaticojejunostomy anastomosis. Minimally invasive approach is an interest in this particular field since a majority of these patients are children. Decreased postoperative pain and faster recovery time may translate into limiting their absence from school and other activities important to their development. It is also more cosmetically appealing.

To date, laparoscopic excision of choledochal cysts and subsequent reconstruction have only been described in case reports or series in the pediatric population.37–40 The largest pediatric series reported nine patients, however, the hepaticojejunostomy anastomosis was performed extracorporeally.39 In a series of 12 adult patients, the mean operative time for excision and a Roux-en-Y reconstruction was 228 minutes with an average length of hospital stay of 5.8 days. In addition, they reported no mortalities nor anastomotic complications.41 Under laparoscopic guidance, the enlarged bile duct and gallbladder (if present) are excised. End-to-side biliary-enteric anastomosis is created with a continuous suture and the jejunojejunostomy can be accomplished with a circular or linear stapler.

The advantages of the laparoscopic approach for the management of choledochal cysts are the magnified view afforded by the laparoscope and the potential advantage of less pain and faster recovery. However, the lengthy operative time, the cost of advanced laparoscopic instruments to facilitate laparoscopic performance, and the absence of long-term outcome data are considerable disadvantages. Currently, the laparoscopic management of choledochal cysts will be practiced in centers specialized in minimally invasive hepatobiliary surgery. More studies and refinements in the instruments available are needed to address the disadvantages of this approach.

The application of minimally invasive surgery continues to evolve and is developing at a rapid pace. The success rate for removing stones among accomplished minimally invasive surgeons exceeds 90%. Unfortunately, most surgeons do not currently use a laparoscopic approach to the treatment of CBD stones. This presents significant costs (nearly double) to the patient and the health care system. However, as laparoscopy becomes a more commonplace in surgical practice, the increased cost will be mitigated and the immediate benefits of earlier recovery from laparoscopic surgery will be emphasized. Currently, institutions with hepatobiliary surgeons usually have gastroenterologists who perform ERCPs, thus, it is not mandatory for hepatobiliary surgeons to have the skill sets to laparoscopically treat benign biliary tract pathology in one setting. Nevertheless, laparoscopic management of choledocholithiasis will be a valuable armentarium for the surgeon to have and can be used as a stepping stone for more advanced laparoscopic biliary tract procedures.

Laparoscopic biliary reconstruction is feasible, but it demands long operative times and requires advanced laparoscopic skills as well as significant experience in hepatobiliary surgery. Nevertheless, with careful patient selection as well as a low threshold for conversion to an open approach, certain biliary reconstruction and resection procedures can be completed laparoscopically. The cholecystojejunostomy provides satisfactory biliary bypass in carefully selected patients and is readily accomplished through the minimally invasive technique. Further studies are necessary to accurately determine the long-term patency rates and the utility of more complex laparoscopic biliary-enteric reconstructions.