Retroperitoneal-first laparoscopic approach (Retlap) for congenital biliary dilatation

Abstract

In a resection of congenital biliary dilatation, total excision of the intrapancreatic bile duct is mandatory to eliminate the origin of cancer. However, it should be difficult under the conventional laparoscopic view from the ventral side because the intrapancreatic bile duct is located behind the pancreatic parenchyma and interference between the surgical instruments and the parenchyma is inevitable. For such hepatopancreatobiliary surgery with the high degree of difficulty, we have developed a novel strategy of the retroperitoneal-first laparoscopic approach (Retlap), and applied the case of the congenital biliary dilatation with Todani type Ic. Mobilization of the pancreatic head with Retlap facilitated dissection around the intrapancreatic bile duct in an excellent view from the dorsal side avoiding interference between the instruments and pancreatic parenchyma. Furthermore, CO2 insufflation pressure supported to obtain a good and stable operative field without special assistance. Although improved methods for precise intraoperative identification of the maljunction is required, Retlap should become the standard technique for congenital biliary dilatation.