The Puzzle and Challenge in Treating Hepatolithiasis

Laparoscopic SpyGlass cholangioscopy evaluation during bilioenteric anastomosis for hepatolithiasis, a case report

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Diagnosis and management of benign hepatobiliary diseases are often challenging.

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SpyGlass cholangioscopy has enhanced the diagnosis of biliary diseases.

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A multidisciplinary approach can ensure diagnosis and treatment of patients with hepatobiliary diseases.

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Association of laparoscopic hepaticojejunostomy to SpyGlass cholangioscopy is a safe and minimal invasive procedure.

Introduction

Careful evaluation of intrahepatic injury of biliary tract diseases is crucial to assure proper management and estimate disease prognosis. Hepatholithiasis is a rare condition that can be associated to cholestatic liver diseases. Additional tools to improve diagnosis and patient care are of great interest specially if associated to decreased morbidity. Recently the spread of single-operator platforms of cholangioscopy brought this procedure back to scene. Our aim was to identify safety, feasibility and utility of SpyGlass cholangioscopy of biliary tract during laparoscopic hepaticojejunostomy.

Presentation of case

A 53 years-old man with hepatolithiasis associated to choledolithiasis under treatment with ursodeoxycholic acid and fenofibrate for 8 months, was submitted to laparoscopic hepaticojejunostomy with cholangioscopy for biliary duct evaluation. Spyscope was inserted through a right lateral laparoscopic trocar entering the common bile duct. Examination of intra-hepatic bile ducts showed injury of right biliary. Few microcalculi were visualized. Left biliary ducts presented normal mucosa. Histopathological examination showed a chronic inflammatory process. During the procedure contrasted radiologic images were performed to assure Spyscope location. Following cholangioscopy evaluation, a Roux-en-Y hepaticojejunostomy was performed. To enlarge hepatic duct, a small longitudinal incision was made, and a PDS-5.0 running suture was used for bilioenteric anastomosis. Patient was discharged on postoperative day 6, with drain removal on day 20.

Conclusion

SpyGlass cholangioscopy during laparoscopic hepaticojejunostomy is feasible leading to minimal additional invasion of the surgical. In this case the method was performed safely, providing detailed examination of injured biliary ducts, adding elements to determine disease prognosis and patient care.

Key techniques and procedure optimization of laparoscopic hepatectomy for hepatolithiasis

Hepatolithiasis is a common and refractory benign biliary tract disease in China. Meta-analyses show that laparoscopic hepatectomy (LH) is safe and effective for this disease. LH for hepatolithiasis has its distinctive techniques and procedures due to its unique clinicopathological characteristic in the era of precise hepatecomy and enhanced recovery after surgery. The key techniques include individualized selection of operating hole, hepatic inflow occlusion, anatomical hepatectomy, fine dissection, and other combined techniques. As for procedures, hepatecomy should be completed before extrahepatic bile duct choledocholithotomy is performed, and the portal hepatis should be preferentially dissected before the perihepatic ligaments are separated.