Although CDC are considered benign disorders, prompt treatment is required due to the high chances of progression to severe complications, such as cholangitis, pancreatitis, cholelithiasis, CDC perforation, and malignant transformations [1]. As prenatally diagnosed CDC tends to develop liver fibrosis immediately after birth, early surgical treatment should be performed in the neonatal period [2].
Presently, radical laparoscopic CDC excision has been widely accepted as a safe, efficacious, and minimally invasive treatment modality for pediatric CDC [7, 8]. Additionally, it has become a common procedure in several medical centers worldwide [3, 8, 12]. Furthermore, robot-assisted choledochal cyst excision is gradually being accepted as another adjunct for minimal surgery in pediatric CDC [5, 13, 14]. The Roux-en-Y jejunal limb is created extracorporeally as per most reports on laparoscope or robot-assist pediatric CDC excision. Meanwhile, a few researchers created Roux-en-Y limbs intracorporeally and proposed intestinal anastomosis with a stapler, and this procedure appears to be safe and feasible for pediatric minimal invasive surgery for CDC [9, 10]. However, due to the usage of robotic surgical and stapling instruments, the cost of both fully robot-assisted and total laparoscope-assisted choledochal cyst excision was much higher than that of conventional laparoscopic cyst excision [9, 10]. Additionally, total robot-assisted choledochal cyst excision was recommended in patients above four years of age [10]. From January 2020, initially, the safety and feasibility of laparoscopic hand-sewn Roux-en-Y jejunal limb created intracorporeally were evaluated in our center. The surgical procedure for radical cyst excision under laparoscopy in 21 children with CDC, including cyst resection, cholecystectomy, hepaticojejunostomy, and hand-sewn Roux-en-Y limb formation was completed successfully. The follow-up was done for 6 to 25 months (median:12 months) with no short-term postoperative complications. The average postoperative time to oral intake, and mean postoperative drainage tube indwelling time were lower than those of the conventional laparoscopic cyst excision surgery [7, 9, 10]. Interestingly, abdominal drainage tubes were not indwelled in two cases due to the absence of visible active exudation on the surgical wound surface after the surgery. The two children recovered smoothly after the surgery and a re-examination was performed three days after the surgery. Reassuringly, no obvious abnormality was noticed during the re-examination. Therefore, further research and exploration should be done to explore whether an indwelling abdominal drainage tube needs to be used after surgery for every child undergoing a total laparoscopic hand-sewn radical cyst excision. Surprisingly, in this study, the surgical cost did not increase significantly compared to conventional laparoscopic surgery because stapler and robotic instruments were not used [9, 10]. Additionally, the youngest patient included in this study was 26 days old. This suggested that age limit criteria may be more flexible in the laparoscopic radical cyst excision for CDC treatment. We assume the laparoscope-assisted hand-sewn Roux-en-Y limb formation has the following advantages. First, since it avoids dragging and exposing the intestine during Roux-en-Y jejunal limb created extracorporeally, the intestine is less disturbed during the surgery, which is related to faster postoperative recovery of gastrointestinal function. Also, the operation of end-to-side jejunal anastomosis is more precise since we can locate the disconnection more precisely due to a clearer view of the vascular arch; the magnification by laparoscopy also enables us to suture the posterior wall of the jejunal end-to-side anastomosis continuously along the full thickness and the anterior wall under the seromuscular layer. Second, age limit is more flexible. Theoretically, pediatric CDC that was suitable for laparoscope-assisted surgery could be treated with total laparoscopic radical cyst excision with a hand-sewing. We do not think the stapler needs to match the intestinal tube diameter in infants. Besides, incision is smaller and more aesthetic as it is not mandatory to expand the umbilical incision and the poke card incision to accommodate the use of endoscopic staplers during the surgery. Surgeons are often unwilling to cut the umbilical cord incision too large when pulling the intestines out from the umbilical cord in the pursuit of beauty, resulting in the compression of the pulled intestines in the umbilical cord, or excessive traction. Such effects may further obstruct the mesenteric venous and cause intestinal congestion, which may affect the recovery of intestinal function and increase the risk of anastomotic bleeding. Moreover, the surgical time was comparable to traditional surgery [9, 10, 15]. As already reported, mechanical anastomoses technically would be easier and surgically faster than intestinal anastomoses in adults [16]. However, a few recent studies have revealed a lower rate of wound infection and postoperative bleeding in the case of hand-sewn anastomoses compared with mechanical ones [16–18]. Although complications, like wound infection and postoperative bleeding, were not seen in the 21 cases of pediatric intestinal anastomosis, the surgical time was not significantly shortened compared with traditional surgery due to the learning curve[15].
Though the preliminary findings of this study demonstrated the safety and feasibility of hand-sewn total laparoscopic radical cyst excision for pediatric CDC, we acknowledged a few limitations, including the relatively small sample size from a single center, short follow-up period, and its retrospective nature. Also, Roux-en-Y limb formation requires a longer learning curve. Surgeons have to be extremely skilled at performing laparoscopic-assisted bowel suturing techniques. We suggest further studies from multiple centers with larger sample size and longer follow-up are needed to validate the benefits of hand-sewn total laparoscopic radical cyst excision.