*7.1.2.1 Choledochoduodenostomy procedure*

The port setting for CDD is similar to the series used for a laparoscopic cholecystectomy. A flexible laparoscope or a 30-degree laparoscope is used through umbilical port. The anterior surface of the bile duct is sharply and bluntly dissected following longitudinal choledochotomy in the supra-pancreatic part of the CBD using microscissors. Incision should be made between 1.5 cm and 2.0 cm in length. After the removal of the stones, a generous Kocher's maneuver should be performed to mobilize the duodenum if needed. A longitudinal duodenostomy is made to prepare the anastomosis to the choledochotomy without tension. The posterior row of

#### **Figure 3.**

*Choledochoduodenostomy A, side-to-side anastomosis, B, posterior row of running suture, C, completion of posterior row suture, D, completion of anterior row running suture. # indicates placement of interlock suture. Originatd from Ref. [25].*

*Minimally Invasive Treatment for Cholelithiasis DOI: http://dx.doi.org/10.5772/intechopen.98874*

sutures should be placed in a running fashion followed the anterior row sutures can be completed as the same fashion [25]. There are some discussions about whether a side-to-side or end-to-side anastomosis of the CDD is prefer in the laparoscopic surgery. The side-to-side anastomosis is used much often due to only requiring an anterior bile duct wall dissection. So-called "Sump syndrome" can occur with this anastomosis resulting from collecting debris or stones in distal bile duct. The endto-side anastomosis has risks of ischemia and the stenosis due to poor blood supply of the distal bile duct (**Figure 3**).

#### *7.1.3 Laparoscopic choledocho- or hepatioco-jejunostomy (CJ or HJ)*

Laparoscopic choledocho- or hepatico-jejunostomy is a choice of biliary reconstructions when resection or exposure of the proximal bile duct or hepatic duct is required. Roux Y jejunal limb has to be created, resulting in making difficulty of the laparoscopic procedure. CJ or HJ is much advanced techniques, because of requirement of the two anastomosis of CJ or HJ with Roux-en-Y jejuno-jejunostomy.

### *7.1.3.1 CJ or HJ procedure*

The patient is placed in supine position. The ports setting is according to laparoscopic cholecystectomy with some modification. A 5-10 mm port is added in the left mid-upper abdomen for suturing if necessary. In a case of the resection of the extrahepatic bile duct such as a choledochal cyst, CJ or HJ should be performed because of anastomosis tension free. After the careful dissection of the bile duct along the portal vein, the duct is encircled with taping for counter-traction. The duct is dissected up to a planned point toward the duodenum and the hepatic plate followed the division using a stapling device or endoloop. Once the bile duct has been prepared, the Roux jejunal limb is created by dividing the jejunum about 20-30 cm distal to Treitz ligament with stapler. Roux Y limb passes through antecolic route and creates a side-to-side or end-to-side jejuno-jejunostomy with a stapler. CJ or HJ is performed between the bile duct and jejunal small enterostomy using a running suture on both the posterior and anterior walls of the reconstructed jejunum in the end-to-side fashion.
