Introduction: Some authors have described the laparoscopic treatment for Todany type-1 congenital biliary dilatations, also called hepatocholedochus cystic dilatations (HCCD), in adults and children over 6 years of age, showing many advantages of the minimally invasive access. The operative time is usually large due to bleeding and the intracorporeal anastomosis, since none has reported the extracorporeal transumbilical approach for the Roux-en-Y anastomosis (ETUARY), like the one we described for biliary atresia. The purpose of this paper is to present the first cases of HCCD treated laparoscopically in Latin America, for the first time under 4 years old and using the ETUARY.
Patients and Methods: From November/2001 to October/2003, 6 girls with HCCD, aging 1, 3, 4, 4, 6.5 and 8 years old, were operated on laparoscopically. Five children presented cholangitis previously. One girl had a giant 15x13 cm cyst. Using 3 or 4 ports, 2 to 5-mm instrumentsand transparietal traction stitches, the extrahepatic bile tree was dissected down to the intrapancreatic segment, up to the common hepatic duct bifurcation. Both ends were cut, the distal one ligated close to the Wirsung duct entrance. The Roux-en-Y jejunostomy with a 40-cm long hepatic loop, was performed extracorporeally through a umbilical 10-mm incision with a stapler (n=3) or hand-sutured (n=3). The hepato-jejunal anastomosis required manual extracorporeal or intracorporeal suture. All children are being prospectivelly followed-up. Results: Mean operative time: 180 minutes. No conversion. No patient required postoperative intensive care. One required transfusion of 120 mL. One presented light pancreatitis. Mean feeding time: 2.8 days. Hospitalization 4-8 days. There was no perioperative or anesthetic complication. After a follow-up of 6 months to 2 years, all girls are asymptomatic, anicteric with no report of cholangitis, presenting excellent abdominal esthetics. Conclusions: The laparoscopic treatment for HCCD proved to be possible, safe although delicate in experienced hands, using few ports, facilitated by the ETUARY, allowing quick recovery, good esthetics and minimal morbidity even in small children.
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