JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 19, Number 1, 2009 © Mary Ann Liebert, Inc. DOI: 10.1089/lap.2008.0045 Laparoscopic Choledochal Cyst Excision: Lessons Learned in Our Experience Nikunj K. Chokshi, MD, 1 Yigit S. Guner, MD, 1 Arturo Aranda, MD, 1 Mikael Petrosyan, MD, 1 Cathy E. Shin, MD, 1 Henri R. Ford, MD, 1 and Nam X. Nguyen, MD 1,2 Abstract Background: Choledochal cyst (CDC) is a rare biliary disorder. Surgical treatment consists of CDC excision and biliary-enteric reconstruction. Recently, some institutions have reported successful CDC excision by using min- imally invasive techniques. In this study, we report our experience with the laparoscopic management of CDC, with a focus on key operative maneuvers that enhance the likelihood of successful excision. Methods: Following institutional review board approval, we performed a retrospective review of patients who underwent the laparoscopic excision of CDC and Roux-en-Y hepaticojejunostomy. Between October 2003 and November 2007, we performed laparoscopic CDC excision in 9 patients (8 female and 1 male). Median age was 4 years (range, 8 months to 16 years). There were 7 type I and 2 type IV cysts, according to Todani’s classifi- cation. Average cyst size was 4.4 cm (range, 1.3–8.5). The procedures were performed by utilizing four or five trochars. Results: Six of 9 children presented with preoperative pancreatitis, 1 with abdominal pain, 1 with jaundice, and 1 was found incidentally. Three patients required the conversion to laparotomy due to dense adhesions, sec- ondary to pancreatitis. Six patients underwent successful laparoscopic procedures, 5 had complete cyst exci- sions, and 1 underwent a proximal excision with distal mucosectomy. Of the 3 patients who required conver- sion, 2 underwent complete excisions; the other underwent a proximal excision, distal mucosectomy. There were no intraoperative complications. One patient had a postoperative bile leak that required an open hepati- cojejunostomy revision. Eight patients had an uneventful recovery. Oral feedings were resumed within an av- erage of 3.4 days (range, 2–9). Average time to discharge was 6.1 days (range, 5–12). Average follow-up time was 18 months (range, 4–48). No further laboratory abnormalities were detected in any of the patients. Conclusions: Laparoscopic resection of CDC and Roux-en-Y hepaticojejunostomy in children is an excellent treatment option. Preoperative pancreatitis may cause increased technical difficulty, necessitating a conversion. Proximal excision with distal mucosectomy is acceptable when full excision is unsafe. 87 Introduction C HOLEDOCHAL CYST (CDC) DISEASE is a rare, benign biliary disorder that affects 1:100,000 to 1:150,000 children in North America. 1 The disease has a predilection for women (male-to-female ratio approaches 1:4) and a higher incidence in Asia. 2 Because CDC can develop malignant components, the overarching principle of treatment is total excision of the cyst with biliary-enteric reconstruction. Traditionally, the procedure was performed by a laparotomy. In recent years, however, the laparoscopic approach to biliary disase (e.g., cholelithiasis) has become standard, and improvements in instrumentation and laparoscopic techniques have allowed surgeons to perform advanced laparoscopic hepatobiliary surgery. Farrello et al. reported the first laparoscopic resec- tion of a CDC with hepaticojejunostomy in 1995. 3 Since this initial report, several other institutions have presented their initial results with using minimally invasive approaches to advanced hepatobiliary surgery in children. 4–9 These include the laparoscopic approach as well as the use of surgical tele- manipulators. 10 In this study, we report on our experience with the laparoscopic management of CDC, with emphasis 1 Department of Pediatric Surgery, Childrens Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California. 2 Long Beach Memorial Medical Center, Children’s Hospital, Long Beach, California.