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

Abstract

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.

Recurrence of common bile duct stones following laparoscopic common bile duct exploration: a multicenter study

“…Common bile duct stones (CBDS) cause serious medical conditions such as acute cholangitis, gallstone pancreatitis, and severe obstructive jaundice . Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) has become the first‐line therapeutic modality for managing CBDS .…”

Indication and surgical techniques of bypass choledochojejunostomy for intractable choledocholithiasis

“…In the era of prevailing minimally invasive surgeries with laparoscopic or robotic approaches, open RYCJ is not a matter of concern. 12 - 16 Moreover, recent development in ERCP with endoscopic therapeutic intervention has led choledocholithiasis to be placed beyond the territory of surgical indication. 1 - 9 On the contrary, we should not forget that there remains a small number of patients who still require open RYCJ because of the intractable occurrence of CBD stones.…”

“… 10 , 11 There exists an increasing number of case series regarding laparoscopic or robotic RYCJ in the literature, but such minimally invasive surgeries are not regarded as the preferred procedures primarily due to high medical cost and high risk of surgical complications. 12 - 16 Thus, we herein present the detailed procedures of open RYCJ customized for intractable choledocholithiasis.…”

Association of Laparoscopic Methods and Clinical Outcomes of Cholecystolithiasis Plus Choledocholithiasis: A Cohort Study

“…Another surgical method is laparoscopic cholecystectomy + lithotomy of common bile duct + common bile duct primary suture + endoscopic nasobiliary drainage (LCBDPSENBD). 21 Laparoscopic cholecystectomy + lithotomy of common bile duct + common bile duct primary suture + endoscopic nasobiliary drainage can solve all problems with 1 surgery: removing the gallbladder and the biliary stones, placing the nasal bile duct under direct vision of the choledochoscope, suturing the bile duct at one stage to avoid placing the T-tube, and reducing the irritation of the Oddis sphincter. Still, LCBDPSENBD has disadvantages such as bile duct inflammation or unskilled suture, and the incidence of bile leakage is relatively high.…”