Laparoscopic management of variant ductal and vascular anatomy in children with choledochal cysts.

Introduction: Variations in biliary ductal and hepatic vascular anatomy increase the complexity of surgery for choledochal cysts (CDC). The laparoscopic approach for the management of paediatric CDCs with variant anatomy is underreported. This study aimed to describe anatomical variations, operative techniques and early outcomes of laparoscopic hepaticojejunostomy (HJ) in children with CDCs and variant anatomy.

Patients and methods: We conducted a retrospective review of 40 children who underwent laparoscopic CDC excision with HJ between 2019 and 2024 in a single surgical unit. Patients were divided into Group I (with anatomical variations, n = 20) and Group II (without variations, n = 20). Data on demographic details, clinical presentation, imaging findings, pre-operative interventions, ductal and vascular anatomical variations, surgical techniques, intraoperative variables, post-operative complications and outcomes were collected and analysed.

Results: Ductal variations were found in 10 patients, with aberrant right posterior sectoral duct being the most common. Vascular variations were identified in 12 patients, with anteriorly crossing the right hepatic artery (RHA) being the most frequent. Group I had a higher mean age (7.32 vs. 3.57 years, P = 0.014) and longer operative times (415 vs. 364 min, P < 0.0001). Conversion to laparotomy was necessary in 10% of Group I and 15% of Group II patients ( P = 0.634). Post-operative complications, primarily minor (Clavien-Dindo Grade I or II), occurred in 40% of Group I and 30% of Group II ( P = 0.495). Group I had a significantly shorter time to full feeds (72 vs. 80 h, P = 0.015). Both groups had similar post-operative hospital stays and follow-up durations. At the last follow-up, all patients, except one with liver failure in Group II, were asymptomatic with no significant biliary dilatation or liver function abnormalities.

Conclusion: Laparoscopic management of CDCs with variant ductal and vascular anatomy in children is feasible, safe and effective. Detailed pre-operative imaging, meticulous intraoperative assessment and tailored surgical techniques are crucial for successful outcomes.