Three or four ports are typically used. A 4 or 5 mm port is placed at the umbilicus for the camera. The right-hand port (3–5 mm) is inserted in the midclavicular line slightly above the umbilicus. The left hand port (3–5 mm) is inserted in the midclavicular line slightly below the umbilicus. This allows for an operating angle of approximately 90° toward the porta hepatis. If necessary, an additional port may be placed in the anterior axillary line in the right upper quadrant for a liver retractor or an assistant instrument (Fig. 43.2).

A #0 polypropylene transabdominal suture is placed through the falciform ligament to retract the liver upward. A similar suture is placed through the wall of the gallbladder to retract the gallbladder toward the right shoulder. The gallbladder is left in place during the dissection of the cyst to allow for retraction. The cystic duct is isolated and an intraoperative cholangiogram may be done if needed to further define the anatomy. This is rarely necessary given the accuracy of preoperative imaging. The cystic artery and duct are then clipped and divided. The cyst is dissected close to its wall with a combination of blunt dissection and electrocautery with care not to damage the portal vein and hepatic arteries (Fig. 43.3). Dissection should be continued to the bifurcation of the right and left common bile duct, and the common hepatic duct is divided just distal to the bifurcation (Fig. 43.4). Next, distal dissection is performed, and the duct is ligated behind the duodenum into the head of the pancreas so as to remove all biliary epithelial tissue. Ligation is done with a #0 polydioxanone loop (Fig. 43.5). Some advocate not ligating the distal stump, particularly in patients with a stenotic common bile duct radiographically [5]. In patients with repeated cholangitis and significant pericystic inflammation, the anterior wall of the cyst can be opened and a mucosectomy performed. This leaves the posterior aspect of the cyst wall intact to avoid damage to the portal vein while removing the biliary epithelium which would be at risk for transformation to cholangiocarcinoma in the future [6].

The most common types of reconstruction are the Roux-en-Y hepaticojejunostomy (HJ) and the hepaticoduodenostomy (HD) . HD is technically easier given the proximity of the duodenum to the hepatic confluence, more physiologic, avoids complications associated with the Roux-en-Y, and allows for postoperative access to the anastomosis if required [7]. In a meta-analysis, the two types of reconstructions had similar postoperative complications. The HD group showed shorter operative times, decreased length of stay, and a higher rate of gastric reflux [8].

For the HD technique, the duodenum is completely Kocherized to prevent tension on the duodenum and anastomosis. A longitudinal duodenostomy is created at least 2 cm distal to the pylorus, on the antimesenteric side of the second portion of the duodenum (Fig. 43.6). The anastomosis is then performed using interrupted 4–0 polydioxanone sutures. The back wall is sutured first with the knots intraluminally (Fig. 43.7). At the corners, the knots are placed extraluminal, and then the anterior portion of the anastomosis is completed (Fig. 43.8). Finally, the gallbladder is freed from the liver, and the gallbladder along with the cyst is placed in a specimen bag and removed through the umbilical port site. A closed suction drain is usually left behind the anastomosis. There are reports supporting avoidance of drains after CDC excision, arguing that it is unnecessary in the majority of patients and minimizes postoperative pain and drain complications [9].