Safety and efficacy of a novel continuous incision technique for laparoscopic transcystic choledocholithotomy

Laparoscopic Ultrasound-Guided Transcystic Approach for the Treatment of Common Bile Duct Stones

Background: The treatment of choledocholithiasis with nondilated common bile duct (CBD) is a challenge for surgeons who often choose endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (LC) staging surgery instead of simultaneous laparoscopic CBD exploration with LC because of the small CBD diameter. This study aims to introduce and assess the clinical applicability of a technique we developed to identify and extract CBD stones using laparoscopic ultrasound (LUS). Methods: We retrospectively reviewed surgical procedures and clinical data of 13 patients who underwent LC and CBD exploration using LUS between May 2022 and August 2023. The cystic duct was used for CBD stone removal. Results: Ten patients were successfully treated; 2 patients with residual stones were treated with ursodeoxycholic acid, whereas 1 patient required a microincision near the CBD and choledochoscopy because of stone incarceration in the duodenal papilla. The CBD diameter was 6 mm (5-9 mm). There were less than three CBD stones, with diameters of 2-6 mm; the median operative time was 105 minutes (range, 52-155 minutes). One patient developed postoperative cholangitis. The median postoperative hospital stay was 6 days (3-8 days). The stone clearance rate was 76.9%, and the CBD stone detection rate was 100%. No intraoperative complications, postoperative bile leakage, and mortality occurred. Conclusions: CBD exploration and transcystic stone extraction under LUS guidance are safe and effective approaches for patients with choledocholithiasis; strict control over surgical indications is necessary. This study could provide new strategies for effectively treating choledocholithiasis.

Laparoscopic choledocholithotomy and transductal T-tube insertion with indocyanine green fluorescence imaging and laparoscopic ultrasound: A case report

BACKGROUND

Laparoscopic choledocholithotomy for a large impacted common bile duct (CBD) stone is a challenging procedure because of the technical difficulty and the possibility of postoperative complications, even in this era of minimally invasive surgery. Herein, we present a case of large impacted CBD stones.

CASE SUMMARY

A 71-year-old man showed a distal CBD stone (45 mm × 20 mm) and a middle CBD stone (20 mm × 15 mm) on computed tomography. Endoscopic retrograde cholangiopancreatography failed due to the large size of the impacted stone and the presence of a large duodenal diverticulum. Laparoscopic choledocholithotomy was decided, and we used a near-infrared indocyanine green fluorescence scope to detect and expose the supraduodenal CBD more accurately. Then, the location, size, and shape of the stones were detected using a laparoscopic intraoperative ultrasound. The CBD was opened with a 2-cm-sized vertical incision. After irrigating several times, two CBD stones were removed with the Endo BabcockTM. T-tube insertion was done for postoperative cholangiography and delayed the removal of remnant sludge. The patient had no postoperative complications.

CONCLUSION

Laparoscopic choledocholithotomy by transcholedochal approach and transductal T-tube insertion is a safe and feasible option for large-sized impacted CBD stones.

Dual common bile duct examination with transcystic choledochoscopy and cholangiography in laparoscopic cholecystectomy for suspected choledocholithiasis: a prospective study

BACKGROUND

Detection of common bile duct (CBD) stones is a major objective of intraoperative cholangiography (IOC) in laparoscopic cholecystectomy (LC). We evaluated the feasibility and safety of the routine use of transcystic choledochoscopy following IOC (dual common bile duct examination: DCBDE), which may improve the diagnostic accuracy of CBD stones and facilitate one-stage clearance, in LC for suspected choledocholithiasis.

METHODS

Between May 2017 and November 2018, 38 patients with suspected choledocholithiasis were prospectively enrolled in this study, regardless of whether they underwent endoscopic sphincterotomy. Transcystic choledochoscopy was routinely attempted following IOC in LC.

RESULTS

Five cases were excluded due to cholecystitis, bile duct anomaly, or liver cirrhosis. DCBDE was performed in the remaining 33 patients. The biliary tree was delineated by IOC in all patients. Subsequently, choledochosope was performed in 32 patients except for one who was found to have pancreaticobiliary malunion in IOC. The scope was successfully passed into the CBD in 25 (78.1%) patients. Choledochoscopy detected 3 (9.4%) cases of cystic duct stones and 4 (12.5%) cases of CBD stones which were not identified by IOC. All those stones were removed via cystic duct. There were no intra- and postoperative complications, except for two cases of wound infection and one case of a transient increase in serum amylase.

CONCLUSIONS

DCBDE in LC is a safe and promising approach for intraoperative diagnosis and one-stage treatment of suspected choledocholithasis.

Five-year follow-up outcomes of laparoscopic choledochoscopy via the cystic duct for choledocholithiasis in patients with gallstones and common bile duct stones

BACKGROUND

There are many treatments for gallstones combined with common bile duct stones. Currently, laparoscopic cholecystectomy plus common bile duct exploration and endoscopic sphincterotomy plus laparoscopic cholecystectomy are often used, but T tube drainage is required for the former, and the latter is controversial due to the destruction of the Oddi sphincter.

AIM

To investigate the clinical effect of laparoscopic choledochoscopy in the treatment of gallstones with common bile duct stones.

METHODS

A total of 125 patients who underwent laparoscopic choledochoscopy and cholecystectomy for gallbladder stones and common bile duct stones were followed for 5 years from January to December 2013. The clinical effects were analyzed.

RESULTS

The operation was successful in 122 cases, with a success rate of 97.6%. The average age of the patients was 58.21 ± 13.01 years old. The mean operation time was 87.95 ± 39.12 min, and mean intraoperative blood loss was 11.27 ± 6.85 mL. All patients underwent balloon dilatation, of whom 33 underwent microctomy at the confluence of the cystic duct and 5 underwent lithotrity via choledochoscopy. The mean time to first postoperative exhaust was 32.48 ± 17.85 h, and mean postoperative hospital stay was 2.03 ± 1.62 d. The rate of complications at short-term follow-up was 5.74%, and there were a total of 7 cases, including 4 cases of postoperative pancreatitis cured by symptomatic treatment with octreotide and ulinastatin, 2 cases of bile leakage cured by ENBD drainage, and 1 case of surgical wound infection cured by re-dresses. The rate of complications at 5-year follow-up was 4.92%, and there were 4 cases of recurrent common bile duct stones, including 1 case with intrahepatic bile duct stones and 2 cases with pancreatitis. Four patients died, of whom two patients had a myocardial infarction, one had a lung infection, and one had a car accident, all of which were not related to the operation.

CONCLUSION

Laparoscopic choledochoscopy for the treatment of gallbladder stones combined with common bile duct stones has both good short- and long-term results, with the advantages of little trauma, rapid recovery, and few complications.

Comprehensive and innovative techniques for laparoscopic choledocholithotomy: A surgical guide to successfully accomplish this advanced manipulation

Surgeries for benign diseases of the extrahepatic bile duct (EHBD) are classified as lithotomy (i.e., choledocholithotomy) or diversion (i.e., choledochojejunostomy). Because of technical challenges, laparoscopic approaches for these surgeries have not gained worldwide popularity. The right upper quadrant of the abdomen is advantageous for laparoscopic procedures, and laparoscopic choledochojejunostomy is safe and feasible. Herein, we summarize tips and pitfalls in the actual procedures of choledocholithotomy. Laparoscopic choledocholithotomy with primary closure of the transductal incision and transcystic C-tube drainage has excellent clinical outcomes; however, emergent biliary drainage without endoscopic sphincterotomy and preoperative removal of anesthetic risk factors are required. Elastic suture should never be ligated directly on the cystic duct. Interrupted suture placement is the first choice for hemostasis near the EHBD. To prevent progressive laceration of the EHBD, full-layer interrupted sutures are placed at the upper and lower edges of the transductal incision. Cholangioscopy has only two-way operation; using dedicated forceps to atraumatically grasp the cholangioscope is important for smart maneuvering. The duration of intraoperative stone clearance accounts for most of the operative time. Moreover, dedicated forceps are an important instrument for atraumatic grasping of the cholangioscope. Damage to the cholangioscope requires expensive repair. Laparoscopic approach for choledocholithotomy involves technical difficulties. I hope this document with the visual explanation and literature review will be informative for skillful surgeons.

Transcystic versus traditional laparoscopic common bile duct exploration: its advantages and a meta-analysis

BACKGROUND

The best approach for treating common bile duct stones remains a matter of debate. Traditional laparoscopic common bile duct exploration (LCBDE) can cause adverse events such as stenosis of the bile duct. Moreover, with advances in technology and surgical skills, the use of laparoscopic transcystic common bile duct exploration (LTCBDE) is gradually rising.

OBJECTIVES

To compare the safety, feasibility, and short-term clinical benefits of LTCBDE and LCBDE through matched cases.

METHODS

Web of science, Cochrane, PubMed, and CNKI were searched systematically to identify studies published between January 2007 and December 2017 that compared LTCBDE and LCBDE without a restriction of languages. This meta-analysis was performed using Review Manager 5.3.

RESULTS

Twenty-one studies matched the selection criteria, including 1561 cases of LTCBDE and 1500 cases of LCBDE. There was no obvious difference in stone clearance (OR 1.44, 95% CI 0.84-2.47; P = 0.18). However, LTCBDE had a shorter operative time (MD - 17.72, 95% CI - 19.42 to - 16.02; P < 0.00001) and shorter hospital stay (MD - 2.20, 95% CI - 2.32 to - 2.08; P < 0.00001). Besides, the LTCBDE group showed significantly better results for blood loss (MD - 7.61, 95% CI - 8.85 to - 6.37; P < 0.00001) and postoperative complications (OR 0.28, 95% CI 0.19-0.41; P < 0.00001). In addition, LTCBDE was more cost efficient (MD - 2.51, 95% CI - 2.72 to - 2.30; P < 0.00001). Further, we calculated the absolute mean of operative time (LTCBDE:LCBDE = 97.56:117.81 min), hospital stay (LTCBDE:LCBDE = 5.22:8.91 days), hospital expenses (LTCBDE:LCBDE = 8646.121:11848.31 RMB), blood loss (LTCBDE:LCBDE = 29.3:52.0 ml), the rate of CBD stone clearance (LTCBDE:LCBDE = 92.8:95.0%), and postoperative complications (LTCBDE:LCBDE = 6.7:14.6%) in both groups to obtain more convincing results.

CONCLUSIONS

The stone clearance of LTCBDE was equal to that of LCBDE, and LTCBDE demonstrated a shorter operative time, lower blood loss, and other advantages. Thus, the surgical procedure of laparoscopic transcystic choledochotomy is feasible and safe.