ORIGINAL ARTICLE
Laparoscopic Common Bile Duct Exploration: Choledochotomy Versus Transcystic Approach? Huang Hongjun, MD,*w Jiang Yong, MD, PhD,* and Wu Baoqiang, MD*
Purpose: To compare the difference of primary suture following 3-port laparoscopic common bile duct exploration (LCBDE) between modified transcystic and transcholedochal approach in the treatment of choledocholithiasis. Materials and Methods: Patients who underwent 3-port LCBDE by modified transcystic approach (n = 80) and those who underwent 3-port LCBDE by transcholedochal approach (n = 209) were included in this study. The operative time, duration of hospital stay, diameter of the cystic duct, diameter of the common bile duct (CBD), complications, and demographics were retrospectively analyzed in all patients. Results: All operations were successfully performed. No patient was converted to laparotomy. No mortality was associated with the 2 groups. There was no significant difference between the 2 groups for the operative time (91.94 ± 34.21 min vs. 96.13 ± 32.15 min), duration of hospital stay (9.82 ± 3.48 d vs. 10.74 ± 5.34 d), diameter of cystic duct (0.47 ± 0.09 cm vs. 0.47 ± 0.08 cm), and complications (2.5% vs. 2.87%) (all P > 0.05). A significant difference was observed in terms of the diameter of CBD (1.18 ± 0.29 cm vs. 1.04 ± 0.24 cm P < 0.05). Conclusions: The modified transcystic LCBDE was safe and feasible for treating choledocholithiasis but it might be more suitable for the CBD with a smaller diameter.
study, we retrospectively analyzed and compared the clinical outcomes in patients who underwent LCBDE by modified transcystic approach and those who underwent LCBDE by transcholedochal approach.
MATERIALS AND METHODS Clinical Design This retrospective study was obtained by a verbal consent protocol, and the protocol was approved by the Human Research Ethics Committees of the First People’s Hospital of Changzhou (Third Affiliated Hospital of Soochow University) and the Shaoxing Hospital of China Medical University. The clinical data were collected from January 2008 to October 2012. A total of 289 consecutive patients were included in the present study. There were 126 male patients and 163 female patients, with ages ranging from 17 to 89 years. The mean age was 60 years. The clinical data are shown in Table 1. Magnetic resonance TABLE 1. Comparison of Clinical Demographics Between Modified Transcystic LCBDE and Transcholedochal LCBDE
Modified Transcholedochal Transcystic LCBDE LCBDE (n = 80) (n = 209)
Key Words: laparoscopy, common bile duct, exploration, primary suture
(Surg Laparosc Endosc Percutan Tech 2015;25:218–222)
O
ver the past 2 decades, laparoscopic common bile duct exploration (LCBDE) has all the advantages of minimal access and is most cost effective compared with the other options for treatment of choledocholithiasis.1–3 Basically, LCBDE can be divided into several procedural variations: transcystic or transcholedochal approach with primary closure or T-tube drainage. Of which, transcystic LCBDE with primary closure is the most ideal. It can clear the CBD stones completely and leave the integrated CBD and sphincter of the duodenal papilla intact. However, it is limited by the anatomy of the cystic duct, the size, number, and location of CBD stones, etc.4 To avoid those deficiencies, our previous study reported the modified transcystic LCBDE for choledocholithiasis.5 In the present Received for publication March 23, 2014; accepted January 22, 2015. From the *Department of Hepatobiliary Surgery, The First People’s Hospital of Changzhou, Soochow University, Changzhou, Jiangsu; and wDepartment of Hepatobiliary Surgery, The Shaoxing Hospital of China Medical University, Shaoxing, Zhejiang, China. Presented at the First People’s Hospital of Changzhou, Jiangsu, China. The author declares no conflicts of interest. Reprints: Jiang Yong, MD, PhD, Department of Hepatobiliary Surgery, The First People’s Hospital of Changzhou, Soochow University, Changzhou, Jiangsu 213003, China (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Age(y) Sex (F/M) Abnormal LFT Incidence of jaundice (%) Preoperative ERCP + EST (%) Biliary pancreatitis (%) Acute cholangitis (%) Extra-hepatic bile duct stones (%) Mirizzi syndrome (type I) (%) Gallbladder carcinoma (%) Duodenal fistula (%)
P
60 ± 16.7 28/52 25.0
58 ± 16.63 98/111 65.1
0.36 0.09 < 0.0001
18.8
52.6
< 0.0001
15.0
9.6
0.21
2.5
6.7
0.25
1.3
15.8
1.00
0
0.5
1.00
0
0.5
1.00
0
0.5
1.00
0
0.5
1.00
ERCP indicates endoscopic retrograde cholangiopancreatography; EST, endoscopic sphincterotomy; LCBDE, laparoscopic common bile duct exploration; LFT, liver function test.
Surg Laparosc Endosc Percutan Tech
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Volume 25, Number 3, June 2015
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 3, June 2015
Laparoscopic Common Bile Duct Exploration
cholangiopancreatography (MRCP) was performed routinely before operation. Patients were divided into 2 groups: those who underwent 3-port LCBDE by transcholedochal approach (n = 209) and those who underwent 3-port LCBDE by transcystic approach (n = 80). All of them underwent primary bile duct closure.
Surgical Procedures After general anesthesia was administered, the operation was carried out using the 3-port technique. The first port (A) was a 10-mm supraumbilical camera port with 12 mm Hg (1 mm Hg = 0.133 kPa) CO2 insufflation. The other 2 ports, a 12 mm subxiphisternal (B) port and a 5 mm upper right quadrant (C) port, were inserted under 3-dimensional laparoscopic vision (Storz, Tuttlingen, Germany)6 (Fig. 1). Firstly, the operation began with dissection of Calot’s triangle and division of the cystic duct and the artery.7 Secondly, according to the diameter of the common bile duct, the operator determined the next modus operandi—transcystic or transcholedochal approach with primary closure. Finally, the cystic duct was transected between the lateral catgut ligature and the clipped neck of the gallbladder. A silicon subhepatic drain was routinely placed in all patients, which was the drainage tube hole leading to C.
Modified Transcystic LCBDE Cystic artery was ligated with a Hem-o-lock (Tyco) and cut off by the electric coagulation. After the cystic duct was exposed sufficiently, a longitudinal incision was made from the antetheca of the cystic duct to CBD, so that the choledochoscope could insert CBD. As a stone removal method, the CBD was washed via suction with a soft pipe, that is, a 3 to 4 cm soft pipe was connected to a suction device, the other end of the pipe was inserted into the intrahepatic bile duct and the common bile duct (Figs. 2 and 3), then distilled water was used to remove the stones from CBD. A choledochoscope was used to explore whether stones remained in the bile duct (Fig. 4). The residual bile duct stones were retrieved with a wire basket, which passed through the distal CBD into the duodenum to make the distal common bile duct unobstructed. If no intrahepatic or extrahepatic bile duct stones or obstruction was found, the cystic duct was ligated with a Hem-o-lock (Tyco) and the incisions were closed using Vicryl sutures
FIGURE 1. Location of 3 trocars (A–C).
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FIGURE 2. Inserting suction with a soft pipe into common bile duct (CBD)
(Johnson & Johnson) (Fig. 5). Finally, cholecystectomy was performed.
Transcholedochal LCBDE For transcholedochal LCBDE, a longitudinal incision was made at the proximal anterior of the common bile duct. The incision length was depended on the size of the stone. The common bile duct was washed as our modified transcystic LCBDE. Thereafter, a fiber choledochoscope was inserted into the common bile duct and hepatic duct to find stones. Stones were retrieved using a wire basket, which passed through the distal CBD into the duodenum to prevent retained stones from becoming incarcerated in the sphincter of Oddi. Once the stones had been retrieved, the CBD incision was closed with an interrupted suture and the cystic duct was ligated with a Hemo-lock. Next, cholecystectomy was performed.
Follow-up All 289 patients were routinely assessed for 12 months after hospital discharge. B-ultrasonic examination and liver function tests were carried out in every patient.
FIGURE 3. Washing out common bile duct (CBD) stones by suction with a soft pipe.
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significant difference in length of the hospital stay between the transcystic LCBDE group and transcholedochal LCBDE group was found (9.82 ± 3.48 d vs. 10.74 ± 5.34 d, t = 1.43; P > 0.05). There was no significant difference in diameter of cystic duct (0.47 ± 0.09 cm vs. 0.47 ± 0.08 cm, t = 0; P > 0.05) between the 2 groups. However, in diameter of CBD between the 2 groups, statistical difference was observed (1.18 ± 0.29 cm vs. 1.04 ± 0.24 cm, t = 3.84; P < 0.05). A few postoperative complications in both modified transcystic LCBDE group and transcholedochal LCBDE group, including bile leakage and CBD stricture, were discovered. However, these complications had no significant difference between the 2 groups (2.5% vs. 2.87%, P > 0.05).
DISCUSSION FIGURE 4. Using a choledochoscope to explore the bile duct.
Statistical Analysis Statistical analysis of all data was performed using SPSS 13.0 (SPSS Inc., Chicago, IL) program. Continuous data were presented as mean ± SD and categorical data were presented as a proportion (%). Mean comparisons were made using t test. w2 or Fisher’s exact test was used to compare the proportions between groups. P < 0.05 was considered statistically significant.
RESULT The clinical demographics of the 2 groups are shown in Table 1. There were no differences in these demographic between the 2 groups, except for liver function test (LFT) and the incidence of jaundice. All operations were successfully performed. No patient was converted to laparotomy and all patients underwent primary closure. No mortality was associated with the 2 groups. The results are shown in Table 2. The operative time was 91.94 ± 34.21 minutes in the transcystic LCBDE group and 96.13 ± 32.25 minutes in the transcholedochal LCBDE group (t = 0.97, P > 0.05). No
FIGURE 5. Closing the common bile duct (CBD) incision with Vicryl sutures.
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In the present study, we retrospectively analyzed and compared the clinical outcomes in patients undergoing LCBDE between modified transcystic approach and transcholedochal approach. Our data discovered there was no significant difference between the 2 groups in the operative time, duration of hospital stay, diameter of cystic duct, and postoperative complications. Significant difference was only observed in terms of the diameter of CBD. So far, there is no standard surgical treatment for choledocholithiasis. Open CBD exploration and ERCP were the preferred approach for CBD stones.8,9 However, with the development of instruments and the perfection of operative skills, LCBDE for choledocholithiasis is feasible and has become increasingly popular. It is a cost effective, efficient, and minimally invasive method for treating choledocholithiasis.10–12 Unfortunately, the development of an effective and reliable technique for LCBDE is limited by the technical difficulty of the procedure. LCBDE includes transcystic LCBDE and transcholedochal LCBDE with primary suture or T-tube drainage. Overall, primary closure is superior to T-tube drainage.13–16 Some defects of T-tube drainage include17: (1) prolonged hospitalization; (2) low quality of life of the patients; (3) bile loss caused the body fluid imbalance; (4) increased infection of biliary tract rate; and (5) complications caused by loss of T-tube. In contrast, primary closure helps the common bile duct maintain integrity and postoperative normal physiological function. It could decrease postoperative complications and hospital stay. At present, transcystic LCBDE with primary suture is the most ideal operation,18,19 because it can avoid the incision of CBD and the complications of T-tube drainage. Nevertheless, transcystic LCBDE with primary suture has also some limitations. One important limitation is the size of CBD stones should be less than or equal to the diameter of the cystic duct. Otherwise, stones cannot be removed from the cystic duct.20 Meanwhile, the number and the location of stones also are limitations. Thus, it is only suitable for fewer and proximal stones. In addition, it is not suitable for treating intrahepatic bile duct stone because of an angle between the cystic duct and common bile duct.21 To avoid these limitations, we developed a modified transcystic LCBDE with primary suture for treating choledocholithiasis. Traditionally, a standard 4-port approach for LC and LCBDE was used to facilitate the operation. In 2008, a 3-port approach for LCBDE was carried out in the first time in our centre.6 Compared with the 4-port LCBDE, the 3-port LCBDE showed the advantages of minimal invasive
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 3, June 2015
TABLE 2. Comparison of Operative Outcomes Between Modified Transcystic LCBDE and Transcholedochal LCBDE
Operative time (min) Length of hospital stay (d) Diameter of cystic duct (cm) Diameter of CBD (cm) Complication Bile leakage (%) Stricture of CBD (%)
Modified Transcystic LCBDE (n = 80)
Transcholedochal LCBDE (n = 209)
91.94 ± 34.21 9.82 ± 3.48
96.13 ± 32.25 10.74 ± 5.34
0.33 0.15
0.47 ± 0.08
0.47 ± 0.09
1.00
1.04 ± 0.24
1.18 ± 0.29
0.0002
1.25 1.25
2.39 0.48
P
1.00 0.48
CBD indicates common bile duct.
Laparoscopic Common Bile Duct Exploration
our modified transcystic LCBDE was feasible for treating choledocholithiasis. However, we found that there were no significant difference in terms of the operative time, length of hospital stay, complications, and the diameter of cystic duct between transcystic LCBDE and transcholedochal LCBDE with primary suture. The significant difference was found only in the diameter of CBD. These data suggested our transcystic LCBDE might be more suitable for the CBD with a smaller diameter.
CONCLUSIONS The data provided by the present study show that our modified transcystic LCBDE might be more suitable for the CBD with a smaller diameter. Thus, it is safe and feasible for treating choledocholithiasis if there are no residual stones, tumors, or distal CBD patency under choledochoscope. REFERENCES
surgery. The key points of our 3-port approach for LCBDE were as following. (1) The operative field was exposed by making the best body position: left lateral position at 20degree angle, the head upward, and the body at a 30-degree angle against the floor. (2) Surgical gauze was inserted into the foramen of Winslow to prevent the stones from sliding into the lesser omental sac (Fig. 6). (3) Trocar of subxiphisternal was replaced by longer trocar to make the choledochoscope be more easily inserted into CBD. (4) According to the diameter and thickness of CBD, the suture and the distance of the needle were chosen carefully (3-0 to 6-0 Vicryl). In this technique, operators made an incision from the cystic duct till CBD, which let the cystic duct mouth as a part of the incision and decreased the length of incision at the CBD. This technique improved the achievement ratio of transcystic LCBDE and CBD stone extraction. As shown in this study, 78 of 80 patients were successfully cured by our transcystic LCBDE with primary suture, only 1 patient suffered from bile leakage and another patient suffered from CBD stricture. The mean length of postoperative hospital stay was 3 days. This indicated that
FIGURE 6. Inserting surgical gauze into the foramen of Winslow.
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1. Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs singlestage management of patients with gallstone disease and ductal calculi. Surg Endosc. 1999;13:952–957. 2. Varban O, Assimos D, Passman C, et al. Laparoscopic common bile duct exploration and holmium laser lithotripsy: a novel approach to the management of common bile duct stones. Surg Endosc. 2010;24:1759–1764. 3. Rhodes M, Sussman L, Cohen L, et al. Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet. 1998;351:159–161. 4. Lyass S, Phillips EH. Laparoscopic transcystic duct common bile duct exploration. Surg Endosc. 2006;20:S441–S445. 5. Chen XM, Zhang Y, Cai HH, et al. Transcystic approach with micro-incision of the cystic duct and its confluence part in laparoscopic common bile duct exploration. J Laparoendosc Adv Surg Tech A. 2013;23:977–981. 6. Sun DL, Zhang F, Chen XM, et al. Clinical efficacy and safety of selective trans-cystic intra-operative cholangiography in primary suture following three-port laparoscopic common bile duct exploration. Chin Med J (Engl). 2012;125: 3509–3513. 7. Almutairi AF, Hussain YA. Triangle of safety technique: a new approach to laparoscopic cholecystectomy. HPB Surg. 2009;2009:476159. 8. Ghazal AH, Sorour MA, El-Riwini M, et al. Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg. 2009;7: 338–346. 9. Grubnik VV, Tkachenko AI, Ilyashenko VV, et al. Laparoscopic common bile duct exploration versus open surgery: comparative prospective randomized trial. Surg Endosc. 2012; 26:2165–2171. 10. Savita KS, Bhartia VK. Laparoscopic CBD exploration. Indian J Surg. 2010;72:395–399. 11. Shelat VG, Chan CY, Liau KH, et al. Laparoscopic exploration can salvage failed endoscopic bile duct stone extraction. Singapore Med J. 2012;53:313–317. 12. Kharbutli B, Velanovich V. Management of preoperatively suspected choledocholithiasis: a decision analysis. J Gastrointest Surg. 2008;12:1973–1980. 13. El-Geidie AA. Is the use of T-tube necessary after laparoscopic choledochotomy?. J Gastrointest Surg. 2010;14:844–848. 14. Wu X, Yang Y, Dong P, et al. Primary closure versus T-tube drainage in laparoscopic common bile duct exploration: a meta-analysis of randomized clinical trials. Langenbecks Arch Surg. 2012;397:909–916.
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15. Sikic N, Tutek Z, Strikic N. Primary suture vs. T-tube after common bile duct exploration (our 25 years of experience). Przegl Lek. 2000;57:143–145. 16. Gurusamy KS, Samraj K. Primary closure versus T-tube drainage after laparoscopic common bile duct stone exploration. Cochrane Database Syst Rev. 2007;24:CD005641. 17. Leida Z, Ping B, Shuguang W, et al. A randomized comparison of primary closure and T-tube drainage of the common bile duct after laparoscopic choledochotomy. Surg Endosc. 2008; 22:1595–1600. 18. Wagner AJ, Traverso LW. the importance of attempting transcystic laparoscopic common bile duct (CBD) explor-
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ation in cases of cbd stones (CBDs). Surg Endosc. 2006; 20:178. 19. Hanif F, Ahmed Z, Samie MA, et al. Laparoscopic transcystic bile duct exploration: the treatment of first choice for common bile duct stones. Surg Endosc. 2010;24:1552–1556. 20. Bove A, Bongarzoni G, Palone G, et al. Why is there recurrence after transcystic laparoscopic bile duct clearance? risk factor analysis. Surg Endosc. 2009;23:1470–1475. 21. Gough V, Stephens N, Ahmed Z, et al. Intrahepatic choledochoscopy during trans-cystic common bile duct exploration; technique, feasibility and value. Surg Endosc. 2012;26: 3190–3194.
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Laparoscopic Common Bile Duct Exploration: Choledochotomy Versus Transcystic Approach? Huang Hongjun, MD,*w Jiang Yong, MD, PhD,* and Wu Baoqiang, MD*
Purpose: To compare the difference of primary suture following 3-port laparoscopic common bile duct exploration (LCBDE) between modified transcystic and transcholedochal approach in the treatment of choledocholithiasis. Materials and Methods: Patients who underwent 3-port LCBDE by modified transcystic approach (n = 80) and those who underwent 3-port LCBDE by transcholedochal approach (n = 209) were included in this study. The operative time, duration of hospital stay, diameter of the cystic duct, diameter of the common bile duct (CBD), complications, and demographics were retrospectively analyzed in all patients. Results: All operations were successfully performed. No patient was converted to laparotomy. No mortality was associated with the 2 groups. There was no significant difference between the 2 groups for the operative time (91.94 ± 34.21 min vs. 96.13 ± 32.15 min), duration of hospital stay (9.82 ± 3.48 d vs. 10.74 ± 5.34 d), diameter of cystic duct (0.47 ± 0.09 cm vs. 0.47 ± 0.08 cm), and complications (2.5% vs. 2.87%) (all P > 0.05). A significant difference was observed in terms of the diameter of CBD (1.18 ± 0.29 cm vs. 1.04 ± 0.24 cm P < 0.05). Conclusions: The modified transcystic LCBDE was safe and feasible for treating choledocholithiasis but it might be more suitable for the CBD with a smaller diameter.
study, we retrospectively analyzed and compared the clinical outcomes in patients who underwent LCBDE by modified transcystic approach and those who underwent LCBDE by transcholedochal approach.
MATERIALS AND METHODS Clinical Design This retrospective study was obtained by a verbal consent protocol, and the protocol was approved by the Human Research Ethics Committees of the First People’s Hospital of Changzhou (Third Affiliated Hospital of Soochow University) and the Shaoxing Hospital of China Medical University. The clinical data were collected from January 2008 to October 2012. A total of 289 consecutive patients were included in the present study. There were 126 male patients and 163 female patients, with ages ranging from 17 to 89 years. The mean age was 60 years. The clinical data are shown in Table 1. Magnetic resonance TABLE 1. Comparison of Clinical Demographics Between Modified Transcystic LCBDE and Transcholedochal LCBDE
Modified Transcholedochal Transcystic LCBDE LCBDE (n = 80) (n = 209)
Key Words: laparoscopy, common bile duct, exploration, primary suture
(Surg Laparosc Endosc Percutan Tech 2015;25:218–222)
O
ver the past 2 decades, laparoscopic common bile duct exploration (LCBDE) has all the advantages of minimal access and is most cost effective compared with the other options for treatment of choledocholithiasis.1–3 Basically, LCBDE can be divided into several procedural variations: transcystic or transcholedochal approach with primary closure or T-tube drainage. Of which, transcystic LCBDE with primary closure is the most ideal. It can clear the CBD stones completely and leave the integrated CBD and sphincter of the duodenal papilla intact. However, it is limited by the anatomy of the cystic duct, the size, number, and location of CBD stones, etc.4 To avoid those deficiencies, our previous study reported the modified transcystic LCBDE for choledocholithiasis.5 In the present Received for publication March 23, 2014; accepted January 22, 2015. From the *Department of Hepatobiliary Surgery, The First People’s Hospital of Changzhou, Soochow University, Changzhou, Jiangsu; and wDepartment of Hepatobiliary Surgery, The Shaoxing Hospital of China Medical University, Shaoxing, Zhejiang, China. Presented at the First People’s Hospital of Changzhou, Jiangsu, China. The author declares no conflicts of interest. Reprints: Jiang Yong, MD, PhD, Department of Hepatobiliary Surgery, The First People’s Hospital of Changzhou, Soochow University, Changzhou, Jiangsu 213003, China (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
218 | www.surgical-laparoscopy.com
Age(y) Sex (F/M) Abnormal LFT Incidence of jaundice (%) Preoperative ERCP + EST (%) Biliary pancreatitis (%) Acute cholangitis (%) Extra-hepatic bile duct stones (%) Mirizzi syndrome (type I) (%) Gallbladder carcinoma (%) Duodenal fistula (%)
P
60 ± 16.7 28/52 25.0
58 ± 16.63 98/111 65.1
0.36 0.09 < 0.0001
18.8
52.6
< 0.0001
15.0
9.6
0.21
2.5
6.7
0.25
1.3
15.8
1.00
0
0.5
1.00
0
0.5
1.00
0
0.5
1.00
0
0.5
1.00
ERCP indicates endoscopic retrograde cholangiopancreatography; EST, endoscopic sphincterotomy; LCBDE, laparoscopic common bile duct exploration; LFT, liver function test.
Surg Laparosc Endosc Percutan Tech
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Volume 25, Number 3, June 2015
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 3, June 2015
Laparoscopic Common Bile Duct Exploration
cholangiopancreatography (MRCP) was performed routinely before operation. Patients were divided into 2 groups: those who underwent 3-port LCBDE by transcholedochal approach (n = 209) and those who underwent 3-port LCBDE by transcystic approach (n = 80). All of them underwent primary bile duct closure.
Surgical Procedures After general anesthesia was administered, the operation was carried out using the 3-port technique. The first port (A) was a 10-mm supraumbilical camera port with 12 mm Hg (1 mm Hg = 0.133 kPa) CO2 insufflation. The other 2 ports, a 12 mm subxiphisternal (B) port and a 5 mm upper right quadrant (C) port, were inserted under 3-dimensional laparoscopic vision (Storz, Tuttlingen, Germany)6 (Fig. 1). Firstly, the operation began with dissection of Calot’s triangle and division of the cystic duct and the artery.7 Secondly, according to the diameter of the common bile duct, the operator determined the next modus operandi—transcystic or transcholedochal approach with primary closure. Finally, the cystic duct was transected between the lateral catgut ligature and the clipped neck of the gallbladder. A silicon subhepatic drain was routinely placed in all patients, which was the drainage tube hole leading to C.
Modified Transcystic LCBDE Cystic artery was ligated with a Hem-o-lock (Tyco) and cut off by the electric coagulation. After the cystic duct was exposed sufficiently, a longitudinal incision was made from the antetheca of the cystic duct to CBD, so that the choledochoscope could insert CBD. As a stone removal method, the CBD was washed via suction with a soft pipe, that is, a 3 to 4 cm soft pipe was connected to a suction device, the other end of the pipe was inserted into the intrahepatic bile duct and the common bile duct (Figs. 2 and 3), then distilled water was used to remove the stones from CBD. A choledochoscope was used to explore whether stones remained in the bile duct (Fig. 4). The residual bile duct stones were retrieved with a wire basket, which passed through the distal CBD into the duodenum to make the distal common bile duct unobstructed. If no intrahepatic or extrahepatic bile duct stones or obstruction was found, the cystic duct was ligated with a Hem-o-lock (Tyco) and the incisions were closed using Vicryl sutures
FIGURE 1. Location of 3 trocars (A–C).
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FIGURE 2. Inserting suction with a soft pipe into common bile duct (CBD)
(Johnson & Johnson) (Fig. 5). Finally, cholecystectomy was performed.
Transcholedochal LCBDE For transcholedochal LCBDE, a longitudinal incision was made at the proximal anterior of the common bile duct. The incision length was depended on the size of the stone. The common bile duct was washed as our modified transcystic LCBDE. Thereafter, a fiber choledochoscope was inserted into the common bile duct and hepatic duct to find stones. Stones were retrieved using a wire basket, which passed through the distal CBD into the duodenum to prevent retained stones from becoming incarcerated in the sphincter of Oddi. Once the stones had been retrieved, the CBD incision was closed with an interrupted suture and the cystic duct was ligated with a Hemo-lock. Next, cholecystectomy was performed.
Follow-up All 289 patients were routinely assessed for 12 months after hospital discharge. B-ultrasonic examination and liver function tests were carried out in every patient.
FIGURE 3. Washing out common bile duct (CBD) stones by suction with a soft pipe.
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significant difference in length of the hospital stay between the transcystic LCBDE group and transcholedochal LCBDE group was found (9.82 ± 3.48 d vs. 10.74 ± 5.34 d, t = 1.43; P > 0.05). There was no significant difference in diameter of cystic duct (0.47 ± 0.09 cm vs. 0.47 ± 0.08 cm, t = 0; P > 0.05) between the 2 groups. However, in diameter of CBD between the 2 groups, statistical difference was observed (1.18 ± 0.29 cm vs. 1.04 ± 0.24 cm, t = 3.84; P < 0.05). A few postoperative complications in both modified transcystic LCBDE group and transcholedochal LCBDE group, including bile leakage and CBD stricture, were discovered. However, these complications had no significant difference between the 2 groups (2.5% vs. 2.87%, P > 0.05).
DISCUSSION FIGURE 4. Using a choledochoscope to explore the bile duct.
Statistical Analysis Statistical analysis of all data was performed using SPSS 13.0 (SPSS Inc., Chicago, IL) program. Continuous data were presented as mean ± SD and categorical data were presented as a proportion (%). Mean comparisons were made using t test. w2 or Fisher’s exact test was used to compare the proportions between groups. P < 0.05 was considered statistically significant.
RESULT The clinical demographics of the 2 groups are shown in Table 1. There were no differences in these demographic between the 2 groups, except for liver function test (LFT) and the incidence of jaundice. All operations were successfully performed. No patient was converted to laparotomy and all patients underwent primary closure. No mortality was associated with the 2 groups. The results are shown in Table 2. The operative time was 91.94 ± 34.21 minutes in the transcystic LCBDE group and 96.13 ± 32.25 minutes in the transcholedochal LCBDE group (t = 0.97, P > 0.05). No
FIGURE 5. Closing the common bile duct (CBD) incision with Vicryl sutures.
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In the present study, we retrospectively analyzed and compared the clinical outcomes in patients undergoing LCBDE between modified transcystic approach and transcholedochal approach. Our data discovered there was no significant difference between the 2 groups in the operative time, duration of hospital stay, diameter of cystic duct, and postoperative complications. Significant difference was only observed in terms of the diameter of CBD. So far, there is no standard surgical treatment for choledocholithiasis. Open CBD exploration and ERCP were the preferred approach for CBD stones.8,9 However, with the development of instruments and the perfection of operative skills, LCBDE for choledocholithiasis is feasible and has become increasingly popular. It is a cost effective, efficient, and minimally invasive method for treating choledocholithiasis.10–12 Unfortunately, the development of an effective and reliable technique for LCBDE is limited by the technical difficulty of the procedure. LCBDE includes transcystic LCBDE and transcholedochal LCBDE with primary suture or T-tube drainage. Overall, primary closure is superior to T-tube drainage.13–16 Some defects of T-tube drainage include17: (1) prolonged hospitalization; (2) low quality of life of the patients; (3) bile loss caused the body fluid imbalance; (4) increased infection of biliary tract rate; and (5) complications caused by loss of T-tube. In contrast, primary closure helps the common bile duct maintain integrity and postoperative normal physiological function. It could decrease postoperative complications and hospital stay. At present, transcystic LCBDE with primary suture is the most ideal operation,18,19 because it can avoid the incision of CBD and the complications of T-tube drainage. Nevertheless, transcystic LCBDE with primary suture has also some limitations. One important limitation is the size of CBD stones should be less than or equal to the diameter of the cystic duct. Otherwise, stones cannot be removed from the cystic duct.20 Meanwhile, the number and the location of stones also are limitations. Thus, it is only suitable for fewer and proximal stones. In addition, it is not suitable for treating intrahepatic bile duct stone because of an angle between the cystic duct and common bile duct.21 To avoid these limitations, we developed a modified transcystic LCBDE with primary suture for treating choledocholithiasis. Traditionally, a standard 4-port approach for LC and LCBDE was used to facilitate the operation. In 2008, a 3-port approach for LCBDE was carried out in the first time in our centre.6 Compared with the 4-port LCBDE, the 3-port LCBDE showed the advantages of minimal invasive
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TABLE 2. Comparison of Operative Outcomes Between Modified Transcystic LCBDE and Transcholedochal LCBDE
Operative time (min) Length of hospital stay (d) Diameter of cystic duct (cm) Diameter of CBD (cm) Complication Bile leakage (%) Stricture of CBD (%)
Modified Transcystic LCBDE (n = 80)
Transcholedochal LCBDE (n = 209)
91.94 ± 34.21 9.82 ± 3.48
96.13 ± 32.25 10.74 ± 5.34
0.33 0.15
0.47 ± 0.08
0.47 ± 0.09
1.00
1.04 ± 0.24
1.18 ± 0.29
0.0002
1.25 1.25
2.39 0.48
P
1.00 0.48
CBD indicates common bile duct.
Laparoscopic Common Bile Duct Exploration
our modified transcystic LCBDE was feasible for treating choledocholithiasis. However, we found that there were no significant difference in terms of the operative time, length of hospital stay, complications, and the diameter of cystic duct between transcystic LCBDE and transcholedochal LCBDE with primary suture. The significant difference was found only in the diameter of CBD. These data suggested our transcystic LCBDE might be more suitable for the CBD with a smaller diameter.
CONCLUSIONS The data provided by the present study show that our modified transcystic LCBDE might be more suitable for the CBD with a smaller diameter. Thus, it is safe and feasible for treating choledocholithiasis if there are no residual stones, tumors, or distal CBD patency under choledochoscope. REFERENCES
surgery. The key points of our 3-port approach for LCBDE were as following. (1) The operative field was exposed by making the best body position: left lateral position at 20degree angle, the head upward, and the body at a 30-degree angle against the floor. (2) Surgical gauze was inserted into the foramen of Winslow to prevent the stones from sliding into the lesser omental sac (Fig. 6). (3) Trocar of subxiphisternal was replaced by longer trocar to make the choledochoscope be more easily inserted into CBD. (4) According to the diameter and thickness of CBD, the suture and the distance of the needle were chosen carefully (3-0 to 6-0 Vicryl). In this technique, operators made an incision from the cystic duct till CBD, which let the cystic duct mouth as a part of the incision and decreased the length of incision at the CBD. This technique improved the achievement ratio of transcystic LCBDE and CBD stone extraction. As shown in this study, 78 of 80 patients were successfully cured by our transcystic LCBDE with primary suture, only 1 patient suffered from bile leakage and another patient suffered from CBD stricture. The mean length of postoperative hospital stay was 3 days. This indicated that
FIGURE 6. Inserting surgical gauze into the foramen of Winslow.
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1. Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs singlestage management of patients with gallstone disease and ductal calculi. Surg Endosc. 1999;13:952–957. 2. Varban O, Assimos D, Passman C, et al. Laparoscopic common bile duct exploration and holmium laser lithotripsy: a novel approach to the management of common bile duct stones. Surg Endosc. 2010;24:1759–1764. 3. Rhodes M, Sussman L, Cohen L, et al. Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet. 1998;351:159–161. 4. Lyass S, Phillips EH. Laparoscopic transcystic duct common bile duct exploration. Surg Endosc. 2006;20:S441–S445. 5. Chen XM, Zhang Y, Cai HH, et al. Transcystic approach with micro-incision of the cystic duct and its confluence part in laparoscopic common bile duct exploration. J Laparoendosc Adv Surg Tech A. 2013;23:977–981. 6. Sun DL, Zhang F, Chen XM, et al. Clinical efficacy and safety of selective trans-cystic intra-operative cholangiography in primary suture following three-port laparoscopic common bile duct exploration. Chin Med J (Engl). 2012;125: 3509–3513. 7. Almutairi AF, Hussain YA. Triangle of safety technique: a new approach to laparoscopic cholecystectomy. HPB Surg. 2009;2009:476159. 8. Ghazal AH, Sorour MA, El-Riwini M, et al. Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg. 2009;7: 338–346. 9. Grubnik VV, Tkachenko AI, Ilyashenko VV, et al. Laparoscopic common bile duct exploration versus open surgery: comparative prospective randomized trial. Surg Endosc. 2012; 26:2165–2171. 10. Savita KS, Bhartia VK. Laparoscopic CBD exploration. Indian J Surg. 2010;72:395–399. 11. Shelat VG, Chan CY, Liau KH, et al. Laparoscopic exploration can salvage failed endoscopic bile duct stone extraction. Singapore Med J. 2012;53:313–317. 12. Kharbutli B, Velanovich V. Management of preoperatively suspected choledocholithiasis: a decision analysis. J Gastrointest Surg. 2008;12:1973–1980. 13. El-Geidie AA. Is the use of T-tube necessary after laparoscopic choledochotomy?. J Gastrointest Surg. 2010;14:844–848. 14. Wu X, Yang Y, Dong P, et al. Primary closure versus T-tube drainage in laparoscopic common bile duct exploration: a meta-analysis of randomized clinical trials. Langenbecks Arch Surg. 2012;397:909–916.
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15. Sikic N, Tutek Z, Strikic N. Primary suture vs. T-tube after common bile duct exploration (our 25 years of experience). Przegl Lek. 2000;57:143–145. 16. Gurusamy KS, Samraj K. Primary closure versus T-tube drainage after laparoscopic common bile duct stone exploration. Cochrane Database Syst Rev. 2007;24:CD005641. 17. Leida Z, Ping B, Shuguang W, et al. A randomized comparison of primary closure and T-tube drainage of the common bile duct after laparoscopic choledochotomy. Surg Endosc. 2008; 22:1595–1600. 18. Wagner AJ, Traverso LW. the importance of attempting transcystic laparoscopic common bile duct (CBD) explor-
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