LAPAROSCOPIC CHOLEDOCHAL CYST EXCISION WITH DUCTOPLASTY AND HEPATICODUODENOSTOMY USING A RIGHT LATERAL APPROACH
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What the experts said
A 4-year-old female presented with abdominal pain and pancreatitis, found to have type 1 choledochal cyst.
The primary surgeon is left-handed.
A modified approach was used to suit the ergonomics of a left-handed surgeon.
5 millimeter metallic reusable trocars were placed as depicted.
The gallbladder and falciform ligament were suspended using a transcutaneous, monofilament absorbable stitch.
The peritoneum overlying the cyst was dissected free with a vessel sealing device.
Meticulous dissection was used to dissect out the right and left hepatic ducts using both blunt and sharp dissection.
The portal vein was not densely adherent to the choledochal cyst structure.
A biliary ductal structure emptying directly into the choledochal cyst was identified, separate from the right and left hepatic ducts.
Needle aspiration was used to confirm the contents of the accessory ductal structure.
The distal portion of the choledochal cyst was ligated with an absorbable tie and divided with a 5 millimeter stapler.
The proximal end of the choledochal cyst was clipped and divided just distal to the confluence of the right and left hepatic ducts.
The accessory duct was clipped and transected sharply.
A ductoplasty was performed between the accessory duct and the common hepatic duct.
The suturing for ductoplasty was done intracorporeally with the left hand being dominant.
The duodenum was mobilized and a duodenostomy was performed sharply, approximately 2.5 centimeters away from the pylorus.
A hepaticoduodenostomy was performed using intracorporeal suturing and knot tying, using the left hand as the dominant hand.
A running stitch was used for the back posterior wall and interrupted stitches were used for the anterior wall of the hepaticoduodenostomy.
The left sided port allowed a forward throw with the left handed suturing technique.
By modifying the port position, excellent ergonomics for the left hand dominant surgeon were achieved.
The completed anastomosis was tension free.
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 handling for left-handed surgeons.
It is possible to modify complex laparoscopic procedures to suit the ergonomics of left-handed surgeons.