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Laparoscopic Revision of Benign Hepaticojejunostomy Stricture










































            Figs 1A to D: (A) Depiction of MDCT showing soft tissue lesion filling hilar bile duct; (B) MRCP showing filling defect; (C) PET-CT increased uptake
            at hilum; (D) PTC demonstrating calculi in CHD and left hepatic duct. Black arrows show the lesions and calculi; white arrow shows HJS

                                                               present case, clinical course, findings on PTC/PTBD led us to a higher
                                                               suspicion of benign stricture with hepatolithiasis. The higher uptake
                                                               on PET-CT seems to be because of inflammation at stricture and
                                                               associated cholangitis corroborated later at surgery and mistaken
                                                               to be a second primary at initial evaluation.
                                                                  Therapeutic options for PDHJS are percutaneous or endoscopic
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                                                               dilatation of the HJS, and surgical revision of the anastomosis.  The
                                                               percutaneous and endoscopic approaches usually require multiple
                                                               sittings to achieve satisfactory dilatation of HJS and are generally
                                                               preferred over a surgical revision which is often accomplished by
                                                               an open operation. There seemed to be a little merit in considering
                                                               an endoscopic approach in a patient with “non-dilatable” HJS by
                                                               percutaneous approach and we elected to do a minimally invasive
                                                               surgical repair.
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                                                                  Zayne B et al. reported feasibility of robotic revision HJ.  By
                                                               planning port placement for the initial adhesiolysis, and with
                                                               patient dissection, the HJS could be clearly delineated. Also, the
                                                               jejunostomy permitted choledochoscopy which confirmed normal
                                                               biliary mucosa, thereby permitting us to proceed with the revision
            Fig. 2: Illustration of port sites; C1, camera port during initial adhesiolysis;
            C2, camera port during later part of procedure; R, right-hand working   surgery. We feel, the previous open pancreaticoduodenectomy
            port; L1, left-hand working port during the initial part of the procedure;   alone should not be a contraindication for repair of PDHJS, among
            L2, left-hand working port during the later part of procedure;   groups with experience in minimally invasive hepatobiliary surgery.
            E, epigastric retraction port                      The laparoscopic approach brings with it the advantages of lesser
                                                               pain; shorter hospital stay; fewer wound-related complications and
            used for diagnosis of HJS are MDCT, MRCP, and PTC which help in   can be achieved at a lesser overall cost than a robotic repair. To our
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            characterizing the lesion as benign or malignant.  Although the   knowledge, this is the first report of laparoscopic revision HJ for HJS
            initial evaluation elsewhere had suggested hilar malignancy in the   following open PD.


            180   World Journal of Laparoscopic Surgery, Volume 15 Issue 2 (May–August 2022)
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