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.