Laparoscopic Transcystic Choledochotomy with Primary Suture for Choledocholith

Abstract

Background and Objectives:To investigate the possibility of extracting common bile duct (CBD) stones by laparoscopically inserting choledochoscope through the natural orifice of the cystic duct and a mini-incision on the CBD, and the safety of laparoscopic primary double-layer suture of the cystic duct and CBD.Methods:Laparoscopic transcystic choledochotomy and extraction of stones with primary suture was performed on 194 patients with gallbladder and CBD stones from October 1, 2009, through April 30, 2012. The cystic duct was left at a diameter of 1 to 1.5 cm after removal of the gallbladder. The duct was longitudinally cut at its ventral side to the confluence with the CBD, and the anterior wall of the CBD was also cut longitudinally. A choledochoscope was then inserted via the enlarged opening, and the stones were extracted from the CBD. Finally, the CBD and cystic duct were closed by continuous mucous layer suture and seromuscular Lembert suture, respectively. The cystic duct was ligated close to the CBD and an abdominal drainage tube was placed.Results:All surgical procedures were successfully performed. The caliber at the confluence between the cystic duct and the CBD was 0.3 to 0.8 cm (SD 0.4 ± 0.1 cm), and the mini-incision of the CBD was 0.1 to 1.1 cm (SD 0.3 ± 0.2 cm). Abdominal drainage lasted 3 to 5 days. Magnetic resonance cholangiopancreatography (MRCP) in 55 patients showed no abnormal change in the CBD diameter. Two patients had bile leakage. Another patient had intermittent abdominal pain and jaundice 5 to 7 days postoperatively, and the retained stones spontaneously passed. The postoperative hospital stay was 6 to 13 days (SD 8 ± 2.1 days). Observation of 176 patients (90%) lasting 1 to 30 months (SD 11 ± 8 months) showed no recurrent stones or stricture of the CBD.Conclusion:The surgical procedure of laparoscopic transcystic choledochotomy and extraction of stones with primary suture is feasible and safe.

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

“…Therefore, we could easily maneuver the choledochoscope into the hepatic duct and common bile duct, and it was not very difficult to suture the right edge of the cystic duct wall and the left edge of the common bile duct. There were no retained stones in the two previous reports or the present study, thus supporting entirely opening the cystic duct to avoid retained stones . Previous studies have considered patients with unsuccessful preoperative EST for BDS to be complex cases , and these assessments are consistent with this study.…”

“…They incised the common hepatic duct and cystic duct, but it may be technically difficult to incise and suture the non‐dilated common hepatic duct. Chen et al reported that intrahepatic bile duct exploration via the transcystic duct failed in 47% of patients with BDS . However, in LTCL, the choledochoscope could clearly visualize both the hepatic and common bile ducts because the bile duct was cut from the orifice, and the ventral side of the bile duct was entirely opened from the orifice.…”

“…Furthermore, it is difficult to explore the bile duct and remove BDS when a patient's common bile duct has a small diameter. Laparoscopic transcystic choledocholithotomy (LTCL) is the preferred method in these circumstances . However, this method has also some limitations relating to the large size of BDS and the difficulty of visualizing the bile duct with the choledochoscope.…”

Evaluation of different methods of laparoscopic treatment of common bile duct stones

“…Chen et al, observed that primary closure is safe after LCBDE (n = 194). 21 Vidagany et al, did primary closure after LCBDE in 160 patients. Bile leakage was reported in only 6.8%.…”

Postoperative rendezvous endoscopic retrograde cholangiopancreaticography as an option in the management of choledocholithiasis

“…On the other hand, minimally invasive laparoscopic and laparo-endoscopic methods have become more frequently used. There are several strategies to manage CBDS but the optimal method as well as timing is still under debate [5,16,[23][24][25][26][27][28][29][30].…”