Surg Endosc (2012) 26:1784–1790 and Other Interventional Techniques

DOI 10.1007/s00464-011-2110-6

Single-incision laparoscopic Roux-en-Y hepaticojejunostomy

using conventional instruments for children with choledochal cysts
Mei Diao • Long Li • Ning Dong • Qi Li •

Wei Cheng

Received: 29 September 2011 / Accepted: 26 November 2011 / Published online: 30 December 2011
Ó Springer Science+Business Media, LLC 2011

Abstract feed, and duration of drainage in the SILH group were

Background Single-incision laparoscopy has recently comparable to our historical controls of CLH (P = 0.056,
become popular in pediatric surgery. Yet there has been no 0.472, 0.619, respectively).
report on its application in the management of choledochal Conclusions In experienced hands, SILH is safe and its
cysts (CDC). The current series is the first study to evaluate short-term results are comparable to CLH. It potentially
the safety and efficacy of single-incision laparoscopic provides a viable surgical alternative for CDC.
hepaticojejunostomy (SILH) for CDC in children.
Methods We reviewed 19 children who underwent SILH Keywords Single-incision
Laparoscopy

between April and June 2011. Early postoperative and Hepaticojejunostomy
Choledochal cysts
Children
follow-up results were compared with our historical
controls.
Results The median follow-up period was 3 months. Two
procedures were converted to the conventional four-port Single-incision laparoscopic surgeries have been increas-
laparoscopic hepaticojejunostomies. SILH was success- ingly utilized in adult surgery. It has been adopted in
fully completed in 17 patients (median age: 3.00 years; cholecystectomies, pyloromyotomies, inguinal hernia
F/M: 12/5). Early in the series, one patient developed bile repairs, high ligation for varicocele, Nissen fundoplica-
leak, which stopped spontaneously after 10 days of drain- tions, endorectal pull-through procedures, and has become
age. The mean operative time of the SILH group did not more common in appendectomies in children [1–4]. In the
differ from that of our conventional laparoscopic hepati- current study, we review our initial experience with single-
cojejunostomy (CLH) controls (3.06 vs. 3.04 h, P = incision laparoscopic cyst excision and Roux-en-Y
0.909). The average postoperative hospital stay, time to full hepaticojejunostomy single-incision laparoscopic hepati-
cojejunostomy (SILH) in children with choledochal cysts
(CDC), and evaluate the safety and feasibility of this new
technique.

M. Diao
L. Li (&)
N. Dong
Q. Li

Department of Pediatric Surgery, Capital Institute of Pediatrics, Materials and methods
Beijing 100020, P. R. China
e-mail: lilong22@hotmail.com From April to June 2011, CDC patients in our center who
W. Cheng (&) were operated on by the same surgeon using a laparoscopic
Department of Paediatric Surgery, Monach Children’s, Monash complete cyst excision and hepaticojejunostomy technique
Medical Center, Southern Health, Department of Paediatrics and were reviewed. Ethics approval from the Ethics Committee
Department of Surgery, Southern Medical School, Faculty of Capital Institute of Pediatrics was obtained. Written
of Medicine, Nursing and Health Sciences, Monash University,
Clayton, Victoria 3168, Australia informed consents were obtained from the parents of the
e-mail: wei.cheng@monash.edu CDC patients before the surgery.

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Single-incision laparoscopic cyst excision and Roux-

en-Y hepaticojejunostomy techniques

The operating table was positioned in a reverse Trendel-

enburg position to facilitate the dissection. The operating
surgeon stood at the foot of the bed between the patient’s
legs and the assistant surgeon stood on the patient’s left
(Fig. 1).
A mid-longitudinal umbilical skin incision was made,
and small skin flaps were raised to expose the muscle
fascia. One 5-mm and two 3-mm fascial incisions were
then made along the same horizontal line at the umbilicus
level. The 5-mm camera port was placed in the midline,
and the two 3-mm working ports were placed lateral to the
camera port at the ends of the umbilical wound, which was
stretched horizontally (Fig. 2). A standard (26011BA, Karl
Storz GmbH & Co. KG, Tuttlingen, Germany) or extra-
long 5-mm 30° laparoscope (26046BA, Karl Storz GmbH
& Co. KG) was inserted through the 5-mm middle port. A
3-mm straight dissector with electrocautery and a 3-mm
straight grasper were placed through the lateral ports.
Carbon dioxide pneumoperitoneum was established at a
pressure of 6–12 mmHg. Fig. 2 External view of the three ports clustered at the umbilicus
Under direct visualization, the intraoperative cholangi- with three retraction sutures through the abdominal wall in a 2-year-
ogram was performed through a 20-gauge angiocatheter old girl with choledochal cyst
puncturing through the abdominal wall and the gallbladder
fundus. abdominal wall at subxiphoid position, hitched the anterior
Extracorporeal stay suture of 2/0 silk on a curved needle wall of the common hepatic duct, and passed out the
was inserted just below the right costal margin and passed abdominal wall below the right costal margin in the mid-
through the serosa of fundus of the gallbladder for cephalad clavicular line (Figs. 2, 3A). This triangular stitch retracted
liver retraction to expose the hepatic hilum (Fig. 2). A the liver and exposed the porta hepatis. The cyst dissection
second 2/0 hitch stitch was passed through the anterior was started anteriorly using a monopolar electrocautery
and continued distally to the posterior duodenal wall
(Fig. 3A). Subsequently, the anterior cyst wall was opened
transversely and the contents were evacuated to enlarge the
working space. The posterior cyst wall was then transected.
The cyst was dissected out close to the cyst wall using
cautery.
A third 2/0 silk transabdominal stay suture was placed to
the middle portion of anterior cyst wall to expose the distal
common bile duct (Fig. 3A, B). The assistant pulled on the
extracorporeal stay suture to facilitate the dissection of
intrapancreatic segment of the common bile duct. Distal
dissection was continued to a level proximal to the biliary-
pancreatic junction to minimize injury to the pancreatic
duct (Fig. 3B). In patients with stenotic distal common bile
duct, the stump of the distal duct was not ligated because it
was friable. In patients with nonstenotic distal common bile
duct, the stump was ligated with a 4/0 absorbable suture to
prevent postoperative pancreatic juice leak, as previously
reported [5]. The proximal cyst was dissected to the hepatic
Fig. 1 Settings of operation room for single-incision laparoscopic hilum (Fig. 3C). The intrahepatic ducts were routinely
cyst excision and Roux-en-Y hepaticojejunostomy scoped, especially in the patients suspected to have hepatic

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Fig. 3 Single-incision
laparoscopic cyst excision and
Roux-en-Y
hepaticojejunostomy.
A Dissection of the distal
choledochal cyst. B Transaction
of the distal choledochal cyst.
C Dissection of proximal
choledochal cyst. D The Roux
loop is brought to the hepatic
hilum through the retrocolic
route. E Posterior wall
anastomosis

duct strictures and calculi. The stenoses were located, 15-cm short segments with 1-needle in each end. The other
incised, and the protein plugs/calculi were evacuated by ends of two short arms were knotted together. End-to-side
irrigation. hepatico-jejunum anastomosis started at 6 o’clock position
The gallbladder was then dissected off the gallbladder of common hepatic duct and proceeded to 9 and 3 o’clock
fossa subserosally with a 3-mm hook electrocautery. The positions separately using continuous sutures (Fig. 4A, B).
suture through the serosa of gallbladder was left behind to Once the posterior wall suture was finished, the trimmed
retract liver in the hepaticojejunostomy. PDS was tightened from 9 and 3 o’clock positions simul-
To minimize redundant Roux loop, an individualized taneously so that the stoma of common hepatic duct and
jejunal Roux loop length was tailored, which was equal to jejunum were approximated properly (Fig. 4C). The ante-
the distance between the umbilicus and the hepatic hilum rior wall anastomosis was completed by continuous suture
[6] and fashioned extracorporeally through the enlarged along the 3–12–9 o’clock direction using the same PDS
umbilical wound. The Roux loop was brought to the hilum suture. The diameter of the anastomosis ranged from 1.0 to
through the retrocolic route (Fig. 3D). End-to-side hepati- 2.0 cm. Then, the retraction sutures were removed. The
co-jejunum anastomosis was accomplished laparoscopi- gallbladder and the choledochal cyst were removed from
cally with continuous 5/0 or 6/0 PDS suture (Fig. 3E). the umbilical trocar site. A suction drain was placed in the
According to the diameter of anastomotic stoma, one subhepatic region through 3-mm working port on the left
double-armed 5/0 or 6/0 PDS was divided into two 10- to side.

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Fig. 4 Posterior common

hepatic duct wall anastomosis.
A and B End-to-side hepatico-
jejunum anastomosis starting at
6 o’clock position of common
hepatic duct and proceeding to 9
and 3 o’clock positions using
two continuous sutures. C The
shortened PDS stitches were
tightened from 9 to 3 o’clock
positions simultaneously so that
the stoma of common hepatic
duct and jejunum were
approximated properly

Incision and arrangement of working ports to the new way of visualization and require more practice
to collaborate with each other.
Single-port with multitrocar requires 2.5-cm umbilical
incision, which may be associated with more pain, more Suture retraction for surgical field exposure
prone to developing an incisional hernia, and may not be and facilitation of dissection and anastomosis
suitable for younger children, especially infants and neo-
nates. In our practice, a smaller incision of 1.5–2.0 cm with Surgical field exposure is crucial in single-incision lapa-
multiple trocars insertion enables the optic lens to be sep- roscopic surgery. In previous reports, a grasper (connected
arated from the operating instruments with smaller wound. to the extra-corporeal retraction system) through the
The two working ports spaced farthest away within the umbilical incision [7] or a MiniLap grasper through a
limits of the skin incision maximizes the extracorporeal separate stab incision [2] were applied for static gallbladder
working space and allows adequate triangulation of the fundus retraction. They occupied more intra- and extra-
straight instruments to perform surgical procedures. Troc- abdominal working space and may result in more collision
arless insertion has been previously advocated for some of instruments.
simple surgical procedures to increase the degree of free- In our practice, employing three transabdominal retrac-
dom [4]. For complicated operations that require frequent tion sutures through the serosa of gallbladder fundus,
changing different working instruments, such as cyst common hepatic duct, and midanterior cyst wall provides
excision and Roux-en-Y hepaticojejunostomy for CDC, we an excellent view of the hepatic hilum and increases intra-
recommend using trocar insertion and removing the 3-mm abdominal working space and range of instrument motion
trocars during hepatico-jejunal anastomosis to maximize for the surgeon. It eliminates additional hand retraction of
freedom of movement of the working instruments. the assistant. It also reduces the cost for additional retrac-
tion system.
Visualization
Posterior wall anastomosis
The relative inline relationship of the telescope with the
working instruments makes visualization very difficult in Posterior wall anastomosis is the most challenging step of
single-incision laparoscopy compared with conventional SILH. Anastomosis at 6 o’clock position of common
laparoscopy. At different steps of the operation, the assis- hepatic duct is difficult. Based on our experience, starting
tant needs to move the telescope back and forth to mini- anastomosis at 6 o’clock position, then suturing along 6–9
mize instrumental collisions and maintain adequate o’clock and 6–3 o’clock directions separately provides a
visualization. Based on our experience, an extra-long clear view of posterior wall and allows more precise
5-mm telescope was used to reduce instrument collisions. anastomosis. We follow the rule of ‘‘doing the hardest part
The operating surgeon and the assistant both need to adapt first’’ and simplify a complicated task into two simple

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procedures. This may reduce the risk of anastomotic subtypes between SILH and CLH in our historical data.
stenosis. Student’s t tests were used to compare the age at operation,
CDC size, operative time, postoperative hospital stay,
Application of conventional straight instruments resumption of alimentation, and duration of drainage
in SILH between the SILH and CLH group in our previous report.
Paired t tests were applied to compare perioperative labo-
A relatively small operating field in pediatric patients was ratory values in SILH. P \ 0.01 was considered to be
thought to facilitate single-incision laparoscopy with statistically significant.
straight instruments. Our comparable operative results and
postoperative morbidities suggest that it is possible to
perform SILH, even in those laparoscopic centers that lack Results
costly special instruments.
Two patients underwent conversions to conventional four-
Follow-up port laparoscopic hepaticojejunostomy. One of them suf-
fered from active inflammation of CDC with severe
Patients were followed up in our clinic at 1, 3, 6, and adhesion, and the other had more than half of the CDC
12 months postoperatively and at 6-month intervals there- embedded in the pancreas requiring extensive dissection.
after. Physical examination, abdominal ultrasonography, SILH was completed in 17 patients (F/M: 12/5). According
and laboratory tests were performed at each visit. Postop- to the Todani’s classification, 14 of 17 patients were type
erative complications, such as bile/pancreatic leak, anas- IV and three were type I CDC. Fourteen of 17 patients were
tomotic stenosis, cholangitis, pancreatitis, intestinal cystic dilatations, and three were fusiform dilatations. The
obstruction, wound infection, or incisional hernia, were diameter of the largest cyst was 8.8 cm.
evaluated clinically and with abdominal ultrasonographic The mean age at operation in SILH group was 3.03 years
studies and laboratory results. Upper gastrointestinal con- (range, 2 months to 9.33 years; B1 year, n = 5; B3 years,
trast studies were performed at 1-month follow-up to assess n = 6;[3 years, n = 6). It was comparable to 4.16 years in
the presence and severity of reflux from the Roux loop into our historical control group (CLH) (P = 0.11; Table 1) [8].
the biliary system. The age at operation, operative blood There was no difference between the two groups in distri-
loss, operative time, postoperative hospital stay, time to bution of gender and CDC subtypes, and CDC size
resume the diet, duration of drainage, intraoperative and (P = 0.736, 0.644, 0.319, and 0.166, respectively; Table 1).
postoperative complications, and perioperative laboratory The operative time shortened from the initial 3.67–1.75 h
values were analyzed and compared with our conventional after the first four patients. The average operative time was
laparoscopic hepaticojejunostomy (CLH) group as previ- 3.06 h, similar to 3.04 h in CLH in our previous study
ously reported [8]. The SILH and CLH were performed by (P = 0.909; Table 2) [8]. Intraoperative blood loss was
the same surgeon. The techniques in SILH and CLH were minimal. No blood transfusion was required. No additional
identical. analgesics were required in either SILH or our historical series
of CLH [9]. The mean postoperative hospital stay, resumption
Statistical analysis of feed, and duration of drainage in SILH were 6.23, 2.64, and
3.23 days, respectively, which did not differ from those in
Data were analyzed with SPSS 13.0 package. v2 test was CLH in our historical controls (7.41, 2.86, 3.05 days,
applied to compare the distribution of gender and CDC P = 0.056, 0.472, 0.619, respectively; Table 2) [8]. The

Table 1 Demographic data comparison between CDC patients who underwent SILH and historical controls who underwent conventional
laparoscopic hepaticojejunostomy (CLH)
SILH (n = 17) CLH (n = 218) P

Female/male ratio 2.4:1 2.89:1 0.736

Age at operation 3.03 year (2 month to 9.3 year) 4.16 year (7 days to 18 year) 0.11
Subtypes
Cystic 14 (82.4%) 169 (77.5%) 0.644
Fusiform 3 (17.6%) 49 (22.5%)
CDC size
Diameter (cm) 4.38 ± 2.48 5.17 ± 3.26 0.319
Length (cm) 5.91 ± 3.18 7.03 ± 3.23 0.166

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Table 2 Comparison of CDC patients who underwent single-incision laparoscopic (SILH) against historical controls who underwent con-
ventional laparoscopic hepaticojejunostomy (CLH)
SILH (n = 17) CLH (n = 218) P

Operative time (h) 3.06 ± 0.54 3.04 ± 0.98 0.909

Postoperative hospital stay (days) 6.23 ± 2.94 7.41 ± 2.39 0.056
Resumption of diet (days) 2.64 ± 0.78 2.86 ± 1.23 0.472
Duration of drainage (days) 3.23 ± 1.92 3.05 ± 1.43 0.619

Table 3 Perioperative laboratory results in choledochal cyst patients who underwent SILH
Preoperation Postoperation P

ALT (U/l) Ref: \40 188.84 ± 99.22 19.32 ± 8.23 \0.001

AST (U/l) Ref: \40 190.84 ± 99.9 21.68 ± 9.98 \0.001
ALP (U/l) Ref: \400 501.47 ± 178.98 117.58 ± 22.47 \0.001
GGT (U/l) Ref: 7–50 369.17 ± 110.32 32.80 ± 11.7 \0.001
TBIL (lmol/l) Ref: 3.4–20 117.1 ± 61.34 10.73 ± 4.98 \0.001
DBIL (lmol/l) Ref: 1.7–13.2 72.5 ± 38.16 3.18 ± 2.4 \0.001
SAMY (U/l) Ref: 25–125 148.54 ± 123.06 38.05 ± 18.41 \0.01
ALT alanine transaminase, AST aspartate aminotransferase, ALP alkaline phosphatase, GGT c-glutamyl transpeptidase, TBIL total bilirubin, DBIL
direct bilirubin, SAMY serum amylase

median follow-up period was 3 months. No mortality or laparoscopic instruments in children. This is the first report
morbidities of anastomotic stenosis, cholangitis, pancreatic of SILH in the surgical literature to date.
leak, pancreatitis, intestinal obstruction, wound infection, After accumulated experience of nearly 300 laparo-
injury of intra-abdominal organs, or incisional hernia was scopic cyst excisions and Roux-en-Y hepaticojejunosto-
observed. Early in this series, a 9-month-old infant developed mies, we started SILH practice in older CDC patients with
bile leak, which subsequently stopped after 10 days of small cysts, and soon extended the practice to younger
drainage. None of type IV CDC patients had intrahepatic duct children and infants with larger cysts. Our results demon-
dilatation detected during postoperative ultrasonographic strate that SILH with conventional straight instruments is
studies. No intrahepatic reflux was observed during postop- safe and feasible. The learning curve is steep in experi-
erative upper gastrointestinal contrast studies. Liver function enced hands. After the first four cases, the operative time of
parameters reversed to normal level at 1 month postopera- SILH is significantly decreased and equivalent to that of
tively (P \ 0.001 and P \ 0.01; Table 3). CLH in our previous report [8]. The postoperative recovery
and duration of drainage are similar to those in the CLH.
The incidence of intraoperative and postoperative compli-
cations in SILH is low, which is comparable to that in
Discussion CLH. The enlarged umbilical incision (1.5–2.0 cm) is
necessary for extracorporeal end-to-side enterostomy for
Previous studies have suggested that visible scarring in the Roux loop in both SILH and CLH. The liver retraction,
children may lead to low self-esteem, impaired socializa- commonly achieved by Nathanson retractor, is replaced by
tion skills, and decrease self-ratings of problem-solving triangular liver retraction stitch and gallbladder fundus
ability [10]. During the recent 3 years, single-incision retraction stitch. The incision and trauma to the abdominal
laparoscopy, as an evolution of minimal invasive surgery, wall has been reduced to the minimum.
has become increasingly popular among pediatric surgeons Two conversions occurred in early our series. We
to achieve a near scarless appearance. It has been applied in believe that a better selection of patients will avoid this
appendectomies, cholecystectomies, pyloromyotomies, complication. Previous studies on the single-incision
enterolysis, ovarian cystectomy, inguinal hernia repairs, laparoscopy have shown that the large size of current
Nissen fundoplications, and endorectal pull-through pro- proprietary multitrocar devices, trocar crowding, limited
cedures [1–4]. In the current series, we reviewed our initial intra-abdominal exposure, clashing instruments, and lim-
experience of SILH using conventional straight ited number of working ports present a practical challenge

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[2]. Special instruments, such as TriPort system, reticu- and achieves comparable results to CLH. SILH may be a
lating instruments, and articulated restraint system, have viable alternative for CDC resection in the future.
been designed for single-incision laparoscopy [7]. Never-
theless, they are expensive, not necessarily available to Disclosures Dr. Mei Diao, Prof. Long Li, Dr. Ning Dong, Dr. Qi Li,
and Prof. Wei Cheng have no conflicts of interest or financial ties to
every laparoscopic center, and require specific training of disclose.
the surgeons. Hence, how to use conventional laparoscopic
instruments and improve technique for single-incision
laparoscopy becomes a new challenge. Our initial SILH
experiences demonstrate that placing working ports at References
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