Laparoscopic kasai portoenterostomy for biliary atresia

Abstract

Despite significant improvements in overall survival for infants suffering from biliary atresia over the past few decades, surgical management of this condition has remained a great challenge for paediatric surgeons. Hitherto Kasais portoenterostomy procedure performed early in life before 810 weeks of age gives the best results for biliary drainage, and is widely accepted as the gold standard operation for biliary atresia. The procedure however entails a large muscle-cutting laparotomy and is associated with significant surgical trauma and postoperative pain as well as other morbidities including respiratory compromise, prolonged ileus and wound complications. Dense intra-abdominal adhesions also often ensue, imposing great difficulties and increased surgical risks should a liver transplantation later become necessary because of progressive biliary cirrhosis and end-stage hepatic failure. Substantial time has to be spent to reopening the abdomen and separating the liver and hilar structures from the surrounding adhesions during the recipient hepatectomy. This is associated with a significant increase in blood loss and risks for bowel perforation and other visceral damage. It can be envisaged that all the aforementioned morbidities could potentially be minimised with minimal access surgery. With the rapid advent of laparoscopic surgery since the early 1990s, many complex and sophisticated reconstructive procedures such as the repair of oesophageal atresia and dismembered pyeloplasty have been successfully performed in newborns and young infants using the minimally invasive surgical techniques. We describe the technique of laparoscopic Kasai portoenterostomy for infants with biliary atresia. Besides all the usual benefits of a minimal access approach, the well-illuminated and magnified laparoscopic view allows superb visibility for meticulous dissection of the hilar structures and the hepaticojejunostomy anastomosis. In addition, laparoscopic inspection with intraoperative cholangiogram also provides an accurate and reliable modality for assessment of infants with prolonged obstructive jaundice. © Springer-Verlag Berlin Heidelberg 2008.