Surgical management for aberrant bile ducts at porta in children undergoing laparoscopic and robotic excision of choledochal malformations.

INTRODUCTION: Choledochal malformations are complex biliary anomalies in children, and their definitive treatment involves cyst excision with bilioenteric reconstruction. The presence of aberrant bile ducts (ABD) at the porta hepatis adds significant technical difficulty and increases the risk of postoperative complications such as bile leak, cholangitis, and segmental stasis if not managed appropriately. The aim of this study was to describe the incidence, classification, and surgical management of ABD encountered during minimally invasive excision of choledochal cysts in children, and to evaluate the feasibility of hepatico-duodenostomy (HD), including ductoplasty and double anastomosis, as a reconstructive strategy.

MATERIALS AND METHODS: We conducted a retrospective cohort analysis of pediatric patients undergoing laparoscopic or robotic choledochal cyst excision at our institution between 2015 and 2022. All patients in whom an ABD was identified either on preoperative MRCP or intra operatively were included. ABDs were classified into three anatomical types according to their relation to the hepatic duct confluence. Reconstructive techniques included single anastomosis, double HD anastomosis, or ductoplasty to unify the ABD with the main hepatic duct. Perioperative findings, operative strategies, and outcomes were assessed.

RESULTS: Of 133 children who underwent minimally invasive choledochal cyst excision, 14 (10.5 %) were found to have ABDs. The mean age was 5.57 ± 2.74 years, and 8 patients were female. Ten underwent laparoscopic and four robotic excisions. MRCP identified ABD preoperatively in only 3 children (21 %), while the remainder were recognized intra operatively. Seven patients underwent single anastomosis, three required double HD anastomoses, and four underwent ductoplasty with single anastomosis. All patients had HD. There were no intraoperative conversions, postoperative bile leaks, or long-term complications. Mean follow-up was 75 ± 38 months, during which all patients remained well with normal liver function and no cholangitis or anastomotic narrowing.

CONCLUSIONS: This is the largest pediatric series describing ABD in association with choledochal cysts, with an overall incidence of 10 %. The proposed classification and numerical denotation system facilitate precise documentation. Hepatico-duodenostomy, including ductoplasty or double anastomosis when necessary, provides a safe and effective reconstructive option while preserving the feasibility of future endoscopic interventions. Recognition and tailored reconstruction of ABD are essential to prevent long-term morbidity.