Everting the Jejunal Mucosa Ensures a Secure Hepaticojejunostomy Anastomosis During Laparoscopic Repair of Choledochal Cyst in Children.

Aim: In children, the diameter at the hepaticojejunostomy anastomosis (HJA) can range from 10 mm to less than 5 mm, irrespective of the type of choledochal cyst (CC). We developed a maneuver that involves everting the mucosa (EM) of the Roux-en-Y loop jejunum and the common hepatic duct mucosa circumferentially, to facilitate suturing during laparoscopic HJA (lap-HJA). Otherwise, it is extremely difficult to distinguish between the lumen and the mucosa on the jejunal side.

Methods

We used EM to treat 18 consecutive children with CC between 2016 and 2018. After transumbilical, extracorporeal Roux-en-Y loop-plasty, the closed end of the jejunum was incised with a scalpel and bleeding points were coagulated with bipolar diathermy. During lap-HJA, the mucosa at the incision was everted circumferentially by using 7/0 absorbable sutures and anastomosed securely to the common hepatic duct by using 5/0 or 6/0 absorbable sutures.

Results

Mean age at surgery was 4.0 years old. HJA diameters were <5 mm (n = 4), 5-9 mm (n = 11), and >9 mm (n = 3). In all cases, EM allowed the lumen at the incision in the Roux-en-Y loop jejunum to be distinguished readily, and suturing proceeded smoothly. After follow-up of a mean of 1.5 years (range 0.5-3.0), no anastomotic leakages or stenoses have been reported.

Conclusions

EM greatly facilitated secure anastomosis during lap-HJA, even when the diameter at the anastomosis was <5 mm. The safety and efficiency of lap-HJA in children with CC could be improved by this simple maneuver.