POSTOPERATIVE DIAGNOSIS: Forme fruste choledochal cyst with
chronic pancreatitis.

NAME OF OPERATION/PROCEDURE: excision of choledochal
cyst with Roux-en-Y biliary reconstruction and cholangiogram.

ANESTHESIA: General.

FINDINGS: At operation, there was some certain amount of
inflammation in the right upper quadrant especially around the
bile ducts. The cholangiography confirmed the presence of a long
common channel. There were no abnormal ducts, otherwise, such as
a low insertion of a right posterior bile duct.

INDICATION FOR PROCEDURE: Patient had been having daily abdominal pain thought to
be due to low-grade pancreatic inflammation. Patient has had three
episodes in the past that had required hospital admission. MRCP
had showed a common channel and abnormally long common channel
between the pancreatic and common bile duct that measured
approximately 2-3 cm.

DESCRIPTION OF OPERATIVE PROCEDURE: Under general anesthesia with
appropriate monitoring lines in place, the patient’s abdomen was
prepped and draped. A time-out was performed and abdomen had been
marked with the appropriate site marking. Patient was given
perioperative cefazolin. A right upper quadrant incision was used
to enter the abdomen. The gallbladder was dissected free from
the gallbladder bed and a cystic duct was cannulated. A cystic
duct cholangiogram was obtained. The result of the cholangiogram
showed an abnormal common bile duct and pancreatic duct junction
with reflux into the intrahepatic bile ducts. The intrahepatic
bile ducts did not have any abnormalities and there were no
anomalus ducts joining the common hepatic duct or the common bile
duct or down.

At the completion of the cholangiogram, a Roux loop was
constructed, which was 40 cm that was constructed by dividing
the jejunum 20 cm distal to the ileocecal valve.

The jejunum was stapled with a GIA stapler. 40 cm beyond the
stapled jejunum, the jejunostomy was made on the
antimesenteric side. The proximal end of the stapled jejunum was
opened and end-to-side jejunojejunostomy was created with a single
running layer of 5-0 PDS. The mesenteric defect was then closed.

We then turned our attention to the common bile duct, which was
divided just proximal to the disappearance of the common duct
behind the pancreatic duct.

A anomalous right hepatic artery was seen behind the common bile
duct as was the portal vein. These structures were carefully
preserved and the adhesions behind the bile duct were carefully
taken down to well beyond the insertion of the cystic duct. We
were able to dissect up more proximally to visualize the common
hepatic duct and could see where the ducts bifurcated. The
proximal transection margin of the common hepatic duct was
approximately 1 cm distal to the bifurcation where the duct was
clearly normal in caliber.

The duct was then spatulated on its anterior border in order to
increase its effective diameter, which was only about 4-5 mm.

The Roux loop which was then brought up behind the retrocolic
fashion had a small enterotomy made on the antimesenteric side
near the stapled end of the Roux. An end-to-side
choledochojejunostomy was done with series of interrupted 6-0 PDS
sutures. No internal stent was made.

We then closed the mesenteric defect in the mesocolon by
reapproximating the cut ends to pull through jejunum.

The distal end of the common bile duct was then inspected and it
was decided not to go ahead and close it since there appeared to
be no pathology beyond it.

We then placed a 10-French Jackson-Pratt drain behind the
choledochojejunostomy and brought out through a small separate
incision. The abdomen was then closed in two layers with running
#0 PDS subcuticular stitch for the skin. A Prolene suture fixing
JP drain in position. The patient was returned to the recovery
room in satisfactory condition.