A new approach to an old problem in laparoscopic common bile duct exploration in the management of hepatolithiasis combined with choledocholithiasis

Abstract

Background: Laparoscopic common bile duct (CBD) exploration using the cholangioscope has become a standardized technique within the last years. However, this technique often becomes a time-consuming, difficult part of the operation and increases the risk of intra-abdominal and surgical site infections due to intraoperative leakage of bile and stone fragments. A new instrument was developed on the basis of using Hi-Lo endotracheal tubes with various manipulative channels included one-way closed suction system, pilot balloon which allows to keep the canal stable in the CBD and available in a wide range of diameters to provide better fit for the different dilatations of the common bile duct. The cholangioscope will be inserted through this canal to remove stones. Methods: We describe the step-by-step technique using the new instrument under laparoscopic guidance, in patients with hepatolithiasis combined with choledocholithiasis. Main outcomes were complete stone clearance rate, single-session stone clearance rate, number of endoscopic sessions needed for stone clearance, and adverse events. Results: A total of 29 patients with hepatolithiasis with choledocholithiasis underwent laparoscopic CBD exploration to remove stones using cholangioscopy through the new instrument from June 2019 to June 2022. 30% of patients had a history of laparotomy, in which 23.8% had a history of CBD exploration. The complete stone clearance rate was 85.7%. Single-sesion stone clearance was achieved in 71.4%. There were no intraoperative complications occurred; 2 cases of postoperative complication of minor bile leakage, no treatment were necessary. The average operative time and tube insertion time was 126 ± 36 minutes and 5 ± 2 minutes, respectively. Postoperative hospital stay was 8.5 ± 2.6 (days). Conclusions: The laparoscopic CBD exploration using the cholangioscope and the new instrument is a feasible, safe, and effective technique, and may be considered as a standard approach of the treatment for hepatolithiasis combined with choledocholithiasis.