Choledochal cysts (CDC), are rare congenital dilations involving the extra hepatic biliary apparatus with or without dilation of the intrahepatic bile ducts. They are conventionally classified into five types. A new type, type VI, causing dilation of the cystic duct between the neck of the gall bladder and the common hepatic duct (CHD) has been described in medical literature which is the rarest of all these subtypes. They are commonly observed in middle aged females and are mostly symptomatic. Most of these cysts need magnetic resonance cholangiopancreatography (MRCP) for accurate diagnosis. Treatment options for these lesions are not well defined but range from simple cholecystectomy to complete excision of the entire bile duct and biliary reconstruction, as there is a concern of malignant transformation in these cysts. Hence, these rare cysts, though rare, must be borne in mind when dealing with suspicious cystic lesions in the biliary tract. Here, we present an interesting case of such a rare cyst and its management in a middle aged woman.

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Background: Pancreaticoduodenectomy (PD) is one of the most formidable surgeries. Even such complicated procedures have been occupied by the minimally invasive approach in far advanced laparoscopic era. We would like to introduce our early experience of totally laparoscopic PD. Materials and methods: The patients were prepared in supine position and five trocars were used. Following resection, all of the reconstructions were accomplished by the laparoscopic approach intracorporeally. The specimen was retrieved through a small extension of skin incision of the umbilical camera port. Result: From March 2014 to August 2015, nine patients underwent laparoscopic PD. Pathology of resected lesions included 3 ampulla of Vater cancer, 2 bile duct cancer, 2 pancreatic cancer, 1 duodenal cancer, and 1 mucinous cystic tumor. Number of nodes harvested was 11.6 AE 2.8. The mean total operative time was 486 AE 84 min, and the mean estimated blood loss was 622 AE 281 ml. One patient was converted to minilaparotomy because of difficult dissection of the uncinate process, which patient had grade B pancreatic leakage. There was no clinically significant complications except previous one patient. The mean length of stay after surgery was 12.8 AE 4.6 days. Conclusion: Despite of worrisome potential risk and complications, laparoscopic PD could be performed safely with competent short-term outcomes. However, it is still a technically demanding and hardship operation during the initial learning curve. Further studies to evaluate long-term favorable outcomes and to develop proper training program for a steep learning curve are required.