Presenter:
Jessica Zagory, MD
Email
@jessicazagory @MarkLikesTrauma @samir_pandya_md @UTSW_Surgery
Jessica Zagory, MD; Mark Ryan, MD; Samir Pandya, MD; UT Southwestern Medical Center
Clinical History: This is a 4-year-old female who initially presented with epigastric abdominal pain and nonbilious emesis. After an inconclusive ultrasound to evaluate for appendicitis, a CT scan was obtained, which demonstrated pancreatic inflammation and a cystic structure within the porta hepatis. The initial lipase level was 6000. An MRCP was then performed, which showed a type 1 choledochal cyst measuring 4.2 cm in diameter. Following resolution of her pancreatitis, she was brought to the operating room two months later for laparoscopic resection of the choledochal cyst.
Operative Technique: Since the primary surgeon was left-handed, we chose a right lateral approach for port placement. We utilized a four-port technique with 5 mm short instruments, a 5 mm vessel sealing device, and a 5 mm stapler. Intraoperatively, an accessory hepatic duct was noted originating from the right posterolateral portion of the cyst. This was sutured intracorporeally to the proximal common hepatic duct to construct a common channel. The hepaticoduodenostomy was performed from the patient’s right side, suturing primarily with the left hand.
Hospital Course: The patient experienced an uneventful recovery. She was started on a regular diet on postoperative day 4. She did not experience postoperative jaundice and bowel movements were normal in appearance. She was discharged on postoperative day 6. Pathology for the specimen was consistent with a choledochal cyst. No subsequent issues were noted at follow up 3 months after discharge.
Intended audience: Healthcare professionals and clinicians.
Laparoscopic cholidocho cyst excision with ductoplasty, hepatocardiolostomy using a right-sided approach. These are our disclosures. A 4 year old female presented with abdominal pain, pancreatitis was found to have type 1 cholidoco cyst. The primary surgeon is left-handed. A modified approach was used to suit the ergonomics of a left-handed surgeon. 45 millimeter metallic reusable trocars were placed as depicted here. The gallbladder and the falciform ligament were suspended up using a transcutaneous, monofilament absorbable stitch. The peritoneum overlying the cyst was dissected free with a vessel sealing device. And once this was done, the cystic duct, common duct, and cholooco cyst were clearly visible. Meticulous dissection was then used to dissect out the right and left hepatic ducts. Blunt dissection as well as sharp dissection was employed. Here you see us lifting the cholioco cyst from the lateral side and examine this lateral aspect. We further dissected this area to determine whether or not the portal vein was densely adherent to the cholioco cyst structure. It was not. As we proceeded with our dissection, we isolated out what appeared to be a biliary ductal structure emptying directly into the cholioco cyst that was separate from the right and left hepatic ducts. This is better delineated right here. Once the structure was skeletonized, needle aspiration was used to confirm the contents of the ductal structure. This is visualized here. The distal portion of the choloidoco cyst is ligated with an absorbable tie, and subsequently, the choloidoco cyst is divided with a 5 millimeter stapler. The proximal end of the cholioco cyst is clipped and divided just distal to the confluence of the right and left hepatic ducts. The accessory duct is also clipped and transected sharply. Here you see the accessory duct and the common hepatic duct in proximity with each other. You also see the cholodocus and gallbladder in situ. The decision was made to perform a ductoplasty between the accessory duct and the common hepatic duct. As you can see, the suturing was done incorporeally with the left hand being dominant. Once the ductoplasty was complete, we then assessed to see if the duodenum would reach for a hepatico duodenostomy. It was mobilized, and a duodenostomy was then performed sharply, approximately 2.5 centimeters away from the pylorus. A hepaco duodenostomy was performed using incorporeal suturing and knot tying, using the left hand as the dominant hand. A running stitch was used for the back posterior wall and the interrupted stitches were used for the anterior wall. The left sided port allowed a forward throw with the left handed suturing technique. By modifying the port position, we were able to take advantage of excellent ergonomics for the left hand dominant surgeon. The picture in picture view shown in the left upper quadrant shows the left-handed suturing from the left subcostal port. The completed anastomosis is shown here and is tension free. In conclusion, at least 10% of surgeons are left-handed. Specific mentoring and access to appropriate instruments for left-handed trainees is lacking. Laparoscopy and laparoscopic instruments do not eliminate problems associated with instrument and handling for left-handed surgeons, but it is possible to modify complex laparoscopic procedures to suit their ergonomics. Thank you.
Click "Show Transcript" to view the full transcription (3389 characters)
Comments