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Early experience with laparoscopic excision of choledochal cyst in 41 children
Journal of Pediatric Surgery (2012) 47, 2175–2178
www.elsevier.com/locate/jpedsurg
Early experience with laparoscopic excision of choledochal cyst in 41 children Bin Wang a , Qi Feng a , Jian-xiong Mao a , Lei Liu a,⁎, Kenneth K.Y. Wong b,⁎ a
Department of General Surgery, Shenzhen Children Hospital, Shenzhen 518026, Guangdong, China Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China b
Received 22 August 2012; accepted 1 September 2012
Key words: Children; Choledochal cyst; Laparoscopy; Minimally invasive surgery
Abstract Objective: This study aims to review our center's early experience in managing children with choledochal cysts using laparoscopic excision. Methods: A retrospective study was carried out from the time of our first case of laparoscopic excision (2010). A total of 41 patients with choledochal cysts underwent laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy. Patient demographics, operative data, and post-operative outcomes were recorded and analyzed. Results: Forty patients underwent the operation successfully, and the mean time of operation was 210 min (range 140 min to 380 min). One case was converted to an open operation due to dense adhesions. All patients recovered uneventfully and were discharged between seven and ten days postoperatively. Four patients suffered minor bile leaks after their operations, but they required only percutaneous drainage. The mean time for follow-up was six months (range 1 month to 1 year). No significant complication was noted during that time. Conclusions: We successfully introduced laparoscopic excision of choledochal cyst in our center and have found this to be a safe and effective method. Long-term follow up is awaited. © 2012 Elsevier Inc. All rights reserved.
Choledochal cyst is an uncommon disease of the biliary tract, with an incidence of around 1:5000 [1]. Although the cause is unknown, an underlying anomalous pancreaticobiliary ductal maljunction is thought to be the etiology [2]. As the condition is known to be a risk for potential malignant ⁎ Corresponding authors. Lei Liu is to be contacted at Department of Surgery, Shenzhen Children's Hospital, Shenzhen 518026, China. Fax: +86 755 83508700. Kenneth K.Y. Wong, Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, Pokfulam Road, Hong Kong. Tel.: +852 22554850. E-mail addresses: [email protected] (L. Liu), [email protected] (K.K.Y. Wong). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2012.09.004
change, the current recommended treatment method is surgical excision and Roux-en-Y hepaticojejunostomy [3,4]. With the advent of laparoscopic surgery, many conditions can now be dealt with using minimally invasive technique. The advantages of laparoscopic surgery are already well documented: less surgical trauma, less bleeding, smaller scars, and faster recovery [5]. Indeed, with the maturation of laparoscopic techniques in out unit, we began to manage more complex conditions such as choledochal cysts laparoscopically in May 2010. Here, we report our early experience of 41 consecutive patients who underwent laparoscopic excision of their choledochal cysts.
2176
1. Materials and methods
B. Wang et al. Table 1
Demographic data of patients with choledochal cysts. Number of patients (%)
Since 2010, we have changed from performing open excision to laparoscopic excision of choledochal cysts. A prospective database was created and this study is a retrospective review of all patients with choledochal cysts since that time. Approval was obtained from the institutional ethics committee. The demographic data, operative data and post-operative outcomes were recorded. For comparison, we also obtained the clinical data of 115 historical patients who received open surgery.
1.1. Surgical technique The technique of laparoscopic excision of choledochal cysts has been well described [6]. Briefly, the patient is positioned supine with head tilted up 20° after general anesthesia. The operating surgeon stands on the right of patient. A 5 mm camera port is inserted trans-umbilically. Three further 5 mm working ports are inserted in the right upper quadrant, right lower quadrant and left upper quadrant. The liver is retracted using a 0 silk suture percutaneously through the falciform ligament. The gallbladder is first mobilized using electrocautery. The choledochal cyst is then identified and dissected out in a similar fashion. The cyst may be opened if it is too large for safe dissection of the posterior wall. Once the distal end of the cyst is reached, it is then ligated and divided. The cyst is then freed to the level between the cystic duct and common hepatic duct, and divided. The Roux loop is then prepared in the usual manner extra-corporeally after the enlargement of the umbilical wound to 2.5 cm. The Roux loop is then returned to the peritoneal cavity and brought through the retrocolic route to the hepatic hilum. Hepatico-jejunostomy is performed using continuous suture on the posterior wall and interrupted on the anterior wall with 5-0 Vicryl.
2. Results Among the 41 patients (14 males and 27 females), the mean age at operation was 4 years old (range two months to twelve years old). The presenting symptoms were shown in Table 1. All patients had the diagnosis confirmed pre-operatively by ultrasound and MRCP. According to Todani's classification [7], 14 cases were Type I, 27 cases were Type IV (Table 1). In three patients, although the sizes of the cyst were between 0.5 to 1 cm, surgical treatment was indicated because of progressive jaundice. Two patients who presented with biliary obstruction had percutaneous drainage prior to laparoscopic resection. Forty patients had successful excision of their choledochal cysts laparoscopically. The operating time ranged from 140 min to 380 min (mean time of 210 min). It was evident from our operative times that the learning curve reached the plateau after case 5 (Fig. 1). Although the estimated amount
Total number Male Female Clinical presentation Jaundice Pain Mass Complete triad Pancreatitis Antenatal diagnosis Anatomical classification I IV Age 2 month–1 year 1 year–5 years 5 years–10 years Size of the cyst 0.5 cm–1.0 cm 1.1 cm–4.0 cm 4.1 cm–10.0 cm N10.0 cm
41 14 (34.1%) 27 (65.9%) 12 32 10 8 14 3
(29%) (78%) (24%) (19%) (34%) (7%)
14 (34%) 27 (66%) 9 (22%) 25 (61%) 7 (17%) 3 18 13 7
(7%) (44%) (32%) (17%)
of bleeding during the operations was between 10 and 20 ml, two patients suffered significant intra-operative bleeding and required transfusion. There was one patient who required conversion to laparotomy because of severe adhesions of the cyst related to previous inflammation. Thirty six patients were discharged from hospital between seven and ten days postoperative. Four patients (4/41, 9.7%) had transient postoperative bile leakage but all healed after conservative management with drainage. In comparison, there were one hundred and fifteen historical patients who had open excision of choledochal cysts. The mean operating time ranged from 157 min to 278 min (mean time of 203 min). The amount of bleeding during operation was between 20 and 60 ml. The recovery time and hospital stay of patients in the laparoscopic group were significant less than those in the open group (p b0.05). Complications were seen in sixteen patients (13.9%). Six had bile leakage, two had pancreatic fistula, massive postoperative bleeding (more than 200 ml) was seen in three patients, with two needing re-laparotomy. Two patients had intestinal obstruction and three had cholangitis. There was no difference in terms of complication rate between open and laparoscopic groups (pN0.05) (Table 2). At follow-up (one month to one year), all patients had normal liver function and ultrasound examination.
3. Discussion Choledochal cysts were first reported by Vater in 1723. Although much research has been devoted to investigating
Laparoscopic excision of choledochal cyst
Fig. 1
2177
Operating times of 41 cases of choledochal cyst.
its etiology, the exact cause is still unknown. Choledochal cyst excision and Roux-en-Y hepaticojejunostomy are the standard operations nowadays. With the rapid development of laparoscopic techniques in recent years, many surgeons have adopted laparoscopic choledochal cyst excision as the treatment of choice [8]. Nonetheless, it is a very complex and difficult operation in children. The advantage of laparoscopic surgery is a clear and magnified operative field, which can clearly show the hepatic artery, the portal vein and all the small vessels around the cyst. This may reduce the risk of bleeding and also avoid injury to these vessels and the pancreas. Indeed, the mean amount of intra-operative blood loss in this series was 10 ml. Furthermore, the laparoscopic approach results in less surgical trauma, quicker recovery, less post-operative pain, and shorter hospital stay. As our technique became more refined, the operative time decreased and stabilized to just over three hours from case five. Of course, one would not expect all surgeons to achieve this plateau after only five cases. Previous experience and proficiency in minimally invasive surgery would be a determining factor. One of our later cases (case 29) took Table 2 Comparison between open and laparoscopic procedures for choledochal cysts.
Operating time (min) Blood loss (ml) Time to full feed (days) Hospital stay Number of complications (%) Bile leakage Pancreatic fistula Postoperative bleeding Intestinal obstruction Cholangitis
Open group
Laparoscopic group
203 29.21±9.32 4.69±0.77 10.25±2.63 16 (13.9%) 6 (5.2%) 2 (1.7) 3 (2.6) 2 (1.7%) 3 (2.6)
210 13.28±4.45 3.71±0.85 7.21±1.58 4 (7.6%) 4 (7.6%) 0 0 0 0
5.8 h due to dense adhesions related to repeated drainage in another hospital. In this series, we also found that laparoscopic resection was technically easier in younger patients. This was due to fewer adhesions from chronic inflammation, as well as smaller cysts. The one case which required conversion to an open procedure was in a twelve year old, because of bleeding at the posterior wall of the common bile duct. The reason for the bleeding was severe adhesions which obliterated the usual plane of dissection. Thus, we would suggest the optimal age to be six months to one year old (the ideal weight of eight to ten kilograms). Furthermore, as most of the choledochal cysts are associated with a very narrow distal outlet, it is not uncommon for patients to be admitted with overt jaundice due to bile duct obstruction. These patients can also undergo early cyst excision without drainage if there is no evidence of cholangitis. Indeed, we have operated successfully on six cases with complete biliary obstruction. Among them, the diameter of cysts was more than five cm in five cases. In order to have a better operating field during laparoscopy, the liver needs to be retracted by applying traction on the falciform ligament. In addition, the gallbladder was first mobilized from the liver in our early series. However, we found that the mobilized gall bladder sometimes obscured our view and interfered with the dissection of the choledochal cyst. Subsequently, we modified our technique so that the mobilization of the gallbladder was not done until the choledochal cyst was completely dissected free. In this way, we would have a clearer surgical field which would contribute to a shorter operative time. With regard to the jejuno-jejunostomy, we have found that although it is possible to perform intracorporeal suturing, the significantly longer operative time needed, as well as the possibility of spilling enteric contents, makes the extracorporeal fashioning of the Roux loop a better choice. Hepaticojejunostomy with a Roux-en-Y anastomosis is the key to the whole operation, as it is one of the most complicated steps and is critical to the success of the surgery
2178 [9]. For the ease of anastomosis, the intestinal wall of the Roux loop is opened more anteriorly, so that the posterior wall can be seen more clearly during suturing. Our early experience has shown that with advanced laparoscopic skills, complex operations like choledochal cyst excision can be performed safely. This procedure appears to be an ideal method to treat choledochal cysts.
References [1] Karrer FM, Hall RJ, Stewart BA, et al. Congenital biliary tract disease. Surg Clin North Am 1990;70:1403-18. [2] Williams NE, Gundara JS, Hugh TJ, et al. Many faces of pancreaticobiliary reflux. ANZ J Surg 2012;82:403-7. [3] She WH, Chung HY, Lan LC, et al. Management of choledochal cyst: 30 years of experience and results in a single center. J Pediatr Surg 2009;44:2307-11.
B. Wang et al. [4] Tang ST, Yang Y, Wang Y, et al. Laparoscopic choledochal cyst excision, hepaticoje-junostomy, and extracorporeal Roux-en-Y anastomosis: a technical skill and intermediate-term report in 62 cases. Surg Endosc 2011;25:416-22. [5] Diao M, Li L, Cheng W. Laparoscopic versus open Roux-en-Y hepatojejunostomy for children with choledochal cysts: intermediateterm follow-up results. Surg Endosc 2011;25:1567-73. [6] Chowbey PK, Katrak MP, Sharma A, et al. Complete laparoscopic management of choledochal cyst: report of two cases. J Laparoendosc Adv Surg Tech A 2002;12:217-21. [7] Calvo-Ponce JA, Reyes-Richa RV, Rodríguez Zentner HA. Cyst of the common hepatic duct: treatment and proposal for a modification of Todani's classification. Ann Hepatol 2008;7:80-2. [8] Li L, Feng W, Jing-Bo F, et al. Laparoscopic-assisted total cyst excision of choledochal cyst and Roux-en-Y hepatoenterostomy. J Pediatr Surg 2004;39:1663-6. [9] Urushihara N, Fukuzawa H, Fukumoto K, et al. Totally laparoscopic management of choledochal cyst: Roux-en-Y jejunojejunostomy and wide hepaticojejunostomy with hilar ductoplasty. J Laparoendosc Adv Surg Tech A 2011;21:361-6.
www.elsevier.com/locate/jpedsurg
Early experience with laparoscopic excision of choledochal cyst in 41 children Bin Wang a , Qi Feng a , Jian-xiong Mao a , Lei Liu a,⁎, Kenneth K.Y. Wong b,⁎ a
Department of General Surgery, Shenzhen Children Hospital, Shenzhen 518026, Guangdong, China Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China b
Received 22 August 2012; accepted 1 September 2012
Key words: Children; Choledochal cyst; Laparoscopy; Minimally invasive surgery
Abstract Objective: This study aims to review our center's early experience in managing children with choledochal cysts using laparoscopic excision. Methods: A retrospective study was carried out from the time of our first case of laparoscopic excision (2010). A total of 41 patients with choledochal cysts underwent laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy. Patient demographics, operative data, and post-operative outcomes were recorded and analyzed. Results: Forty patients underwent the operation successfully, and the mean time of operation was 210 min (range 140 min to 380 min). One case was converted to an open operation due to dense adhesions. All patients recovered uneventfully and were discharged between seven and ten days postoperatively. Four patients suffered minor bile leaks after their operations, but they required only percutaneous drainage. The mean time for follow-up was six months (range 1 month to 1 year). No significant complication was noted during that time. Conclusions: We successfully introduced laparoscopic excision of choledochal cyst in our center and have found this to be a safe and effective method. Long-term follow up is awaited. © 2012 Elsevier Inc. All rights reserved.
Choledochal cyst is an uncommon disease of the biliary tract, with an incidence of around 1:5000 [1]. Although the cause is unknown, an underlying anomalous pancreaticobiliary ductal maljunction is thought to be the etiology [2]. As the condition is known to be a risk for potential malignant ⁎ Corresponding authors. Lei Liu is to be contacted at Department of Surgery, Shenzhen Children's Hospital, Shenzhen 518026, China. Fax: +86 755 83508700. Kenneth K.Y. Wong, Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, Pokfulam Road, Hong Kong. Tel.: +852 22554850. E-mail addresses: [email protected] (L. Liu), [email protected] (K.K.Y. Wong). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2012.09.004
change, the current recommended treatment method is surgical excision and Roux-en-Y hepaticojejunostomy [3,4]. With the advent of laparoscopic surgery, many conditions can now be dealt with using minimally invasive technique. The advantages of laparoscopic surgery are already well documented: less surgical trauma, less bleeding, smaller scars, and faster recovery [5]. Indeed, with the maturation of laparoscopic techniques in out unit, we began to manage more complex conditions such as choledochal cysts laparoscopically in May 2010. Here, we report our early experience of 41 consecutive patients who underwent laparoscopic excision of their choledochal cysts.
2176
1. Materials and methods
B. Wang et al. Table 1
Demographic data of patients with choledochal cysts. Number of patients (%)
Since 2010, we have changed from performing open excision to laparoscopic excision of choledochal cysts. A prospective database was created and this study is a retrospective review of all patients with choledochal cysts since that time. Approval was obtained from the institutional ethics committee. The demographic data, operative data and post-operative outcomes were recorded. For comparison, we also obtained the clinical data of 115 historical patients who received open surgery.
1.1. Surgical technique The technique of laparoscopic excision of choledochal cysts has been well described [6]. Briefly, the patient is positioned supine with head tilted up 20° after general anesthesia. The operating surgeon stands on the right of patient. A 5 mm camera port is inserted trans-umbilically. Three further 5 mm working ports are inserted in the right upper quadrant, right lower quadrant and left upper quadrant. The liver is retracted using a 0 silk suture percutaneously through the falciform ligament. The gallbladder is first mobilized using electrocautery. The choledochal cyst is then identified and dissected out in a similar fashion. The cyst may be opened if it is too large for safe dissection of the posterior wall. Once the distal end of the cyst is reached, it is then ligated and divided. The cyst is then freed to the level between the cystic duct and common hepatic duct, and divided. The Roux loop is then prepared in the usual manner extra-corporeally after the enlargement of the umbilical wound to 2.5 cm. The Roux loop is then returned to the peritoneal cavity and brought through the retrocolic route to the hepatic hilum. Hepatico-jejunostomy is performed using continuous suture on the posterior wall and interrupted on the anterior wall with 5-0 Vicryl.
2. Results Among the 41 patients (14 males and 27 females), the mean age at operation was 4 years old (range two months to twelve years old). The presenting symptoms were shown in Table 1. All patients had the diagnosis confirmed pre-operatively by ultrasound and MRCP. According to Todani's classification [7], 14 cases were Type I, 27 cases were Type IV (Table 1). In three patients, although the sizes of the cyst were between 0.5 to 1 cm, surgical treatment was indicated because of progressive jaundice. Two patients who presented with biliary obstruction had percutaneous drainage prior to laparoscopic resection. Forty patients had successful excision of their choledochal cysts laparoscopically. The operating time ranged from 140 min to 380 min (mean time of 210 min). It was evident from our operative times that the learning curve reached the plateau after case 5 (Fig. 1). Although the estimated amount
Total number Male Female Clinical presentation Jaundice Pain Mass Complete triad Pancreatitis Antenatal diagnosis Anatomical classification I IV Age 2 month–1 year 1 year–5 years 5 years–10 years Size of the cyst 0.5 cm–1.0 cm 1.1 cm–4.0 cm 4.1 cm–10.0 cm N10.0 cm
41 14 (34.1%) 27 (65.9%) 12 32 10 8 14 3
(29%) (78%) (24%) (19%) (34%) (7%)
14 (34%) 27 (66%) 9 (22%) 25 (61%) 7 (17%) 3 18 13 7
(7%) (44%) (32%) (17%)
of bleeding during the operations was between 10 and 20 ml, two patients suffered significant intra-operative bleeding and required transfusion. There was one patient who required conversion to laparotomy because of severe adhesions of the cyst related to previous inflammation. Thirty six patients were discharged from hospital between seven and ten days postoperative. Four patients (4/41, 9.7%) had transient postoperative bile leakage but all healed after conservative management with drainage. In comparison, there were one hundred and fifteen historical patients who had open excision of choledochal cysts. The mean operating time ranged from 157 min to 278 min (mean time of 203 min). The amount of bleeding during operation was between 20 and 60 ml. The recovery time and hospital stay of patients in the laparoscopic group were significant less than those in the open group (p b0.05). Complications were seen in sixteen patients (13.9%). Six had bile leakage, two had pancreatic fistula, massive postoperative bleeding (more than 200 ml) was seen in three patients, with two needing re-laparotomy. Two patients had intestinal obstruction and three had cholangitis. There was no difference in terms of complication rate between open and laparoscopic groups (pN0.05) (Table 2). At follow-up (one month to one year), all patients had normal liver function and ultrasound examination.
3. Discussion Choledochal cysts were first reported by Vater in 1723. Although much research has been devoted to investigating
Laparoscopic excision of choledochal cyst
Fig. 1
2177
Operating times of 41 cases of choledochal cyst.
its etiology, the exact cause is still unknown. Choledochal cyst excision and Roux-en-Y hepaticojejunostomy are the standard operations nowadays. With the rapid development of laparoscopic techniques in recent years, many surgeons have adopted laparoscopic choledochal cyst excision as the treatment of choice [8]. Nonetheless, it is a very complex and difficult operation in children. The advantage of laparoscopic surgery is a clear and magnified operative field, which can clearly show the hepatic artery, the portal vein and all the small vessels around the cyst. This may reduce the risk of bleeding and also avoid injury to these vessels and the pancreas. Indeed, the mean amount of intra-operative blood loss in this series was 10 ml. Furthermore, the laparoscopic approach results in less surgical trauma, quicker recovery, less post-operative pain, and shorter hospital stay. As our technique became more refined, the operative time decreased and stabilized to just over three hours from case five. Of course, one would not expect all surgeons to achieve this plateau after only five cases. Previous experience and proficiency in minimally invasive surgery would be a determining factor. One of our later cases (case 29) took Table 2 Comparison between open and laparoscopic procedures for choledochal cysts.
Operating time (min) Blood loss (ml) Time to full feed (days) Hospital stay Number of complications (%) Bile leakage Pancreatic fistula Postoperative bleeding Intestinal obstruction Cholangitis
Open group
Laparoscopic group
203 29.21±9.32 4.69±0.77 10.25±2.63 16 (13.9%) 6 (5.2%) 2 (1.7) 3 (2.6) 2 (1.7%) 3 (2.6)
210 13.28±4.45 3.71±0.85 7.21±1.58 4 (7.6%) 4 (7.6%) 0 0 0 0
5.8 h due to dense adhesions related to repeated drainage in another hospital. In this series, we also found that laparoscopic resection was technically easier in younger patients. This was due to fewer adhesions from chronic inflammation, as well as smaller cysts. The one case which required conversion to an open procedure was in a twelve year old, because of bleeding at the posterior wall of the common bile duct. The reason for the bleeding was severe adhesions which obliterated the usual plane of dissection. Thus, we would suggest the optimal age to be six months to one year old (the ideal weight of eight to ten kilograms). Furthermore, as most of the choledochal cysts are associated with a very narrow distal outlet, it is not uncommon for patients to be admitted with overt jaundice due to bile duct obstruction. These patients can also undergo early cyst excision without drainage if there is no evidence of cholangitis. Indeed, we have operated successfully on six cases with complete biliary obstruction. Among them, the diameter of cysts was more than five cm in five cases. In order to have a better operating field during laparoscopy, the liver needs to be retracted by applying traction on the falciform ligament. In addition, the gallbladder was first mobilized from the liver in our early series. However, we found that the mobilized gall bladder sometimes obscured our view and interfered with the dissection of the choledochal cyst. Subsequently, we modified our technique so that the mobilization of the gallbladder was not done until the choledochal cyst was completely dissected free. In this way, we would have a clearer surgical field which would contribute to a shorter operative time. With regard to the jejuno-jejunostomy, we have found that although it is possible to perform intracorporeal suturing, the significantly longer operative time needed, as well as the possibility of spilling enteric contents, makes the extracorporeal fashioning of the Roux loop a better choice. Hepaticojejunostomy with a Roux-en-Y anastomosis is the key to the whole operation, as it is one of the most complicated steps and is critical to the success of the surgery
2178 [9]. For the ease of anastomosis, the intestinal wall of the Roux loop is opened more anteriorly, so that the posterior wall can be seen more clearly during suturing. Our early experience has shown that with advanced laparoscopic skills, complex operations like choledochal cyst excision can be performed safely. This procedure appears to be an ideal method to treat choledochal cysts.
References [1] Karrer FM, Hall RJ, Stewart BA, et al. Congenital biliary tract disease. Surg Clin North Am 1990;70:1403-18. [2] Williams NE, Gundara JS, Hugh TJ, et al. Many faces of pancreaticobiliary reflux. ANZ J Surg 2012;82:403-7. [3] She WH, Chung HY, Lan LC, et al. Management of choledochal cyst: 30 years of experience and results in a single center. J Pediatr Surg 2009;44:2307-11.
B. Wang et al. [4] Tang ST, Yang Y, Wang Y, et al. Laparoscopic choledochal cyst excision, hepaticoje-junostomy, and extracorporeal Roux-en-Y anastomosis: a technical skill and intermediate-term report in 62 cases. Surg Endosc 2011;25:416-22. [5] Diao M, Li L, Cheng W. Laparoscopic versus open Roux-en-Y hepatojejunostomy for children with choledochal cysts: intermediateterm follow-up results. Surg Endosc 2011;25:1567-73. [6] Chowbey PK, Katrak MP, Sharma A, et al. Complete laparoscopic management of choledochal cyst: report of two cases. J Laparoendosc Adv Surg Tech A 2002;12:217-21. [7] Calvo-Ponce JA, Reyes-Richa RV, Rodríguez Zentner HA. Cyst of the common hepatic duct: treatment and proposal for a modification of Todani's classification. Ann Hepatol 2008;7:80-2. [8] Li L, Feng W, Jing-Bo F, et al. Laparoscopic-assisted total cyst excision of choledochal cyst and Roux-en-Y hepatoenterostomy. J Pediatr Surg 2004;39:1663-6. [9] Urushihara N, Fukuzawa H, Fukumoto K, et al. Totally laparoscopic management of choledochal cyst: Roux-en-Y jejunojejunostomy and wide hepaticojejunostomy with hilar ductoplasty. J Laparoendosc Adv Surg Tech A 2011;21:361-6.