Laparoscopic excision of choledochal cysts: expect the unexpected

Introduction The standard treatment of choledochal cyst is complete cyst excision with hepatico-enterostomy. However, hepatobiliary anatomical variations can present as intra-operative challenges. Here we present the management of three of our challenging and complicated cases. Methods and results A 5 year-old female presented with complaints of pain abdomen for 1 year. Magnetic resonance cholangiopancreatography (MRCP) was suggestive of Type 4a choledochal cyst. On discussion of MRCP it was noted that cystic duct was opening just distal to the confluence of the right and the left hepatic ducts leaving a very small (3–4 mm) length of the common hepatic duct. Patient was planned for laparoscopic choledochal cyst excision. As we were aware about the anatomy beforehand, we dissected the cystic duct very carefully. The opening of the cystic duct, just distal to the confluence, was properly delineated followed by cystic duct ligation and division taking care of avoiding injury to the right hepatic duct. Choledochal cyst was excised and hepatico-duodenal anastomosis was performed just at the confluence of right and left hepatic ducts. The patient tolerated the procedure well and experienced a smooth post-operative transit. Another case was an 8 year-old boy, who underwent the same procedure for Type 1 choledochal cyst. After 1 month, he presented with massive upper gastrointestinal hemorrhage. He underwent immediate resuscitation and right hepatic artery coiling which proved to be a life-saving procedure in that setting. Thirdly, we excised a case of a giant choledochal cyst 15 × 10 cm size in a 4 year-old child. Conclusion We believe that complex hepatobiliary procedures are suited for laparoscopic surgery. However, proper extensive pre-operative planning and post-operative follow up is mandatory in all cases.