All patients were placed in the supine position under general anesthesia, and the surgeon and second assistant (who held the laparoscope) were positioned to the left side of the patient. The first assistant stood on the opposite side. For the procedure, we used the following four trocars: one 10-mm trocar on the transumbilicus for the scope; one 5-mm trocar on the subxiphoid process for the flexible choledochoscope; and an additional two 5-mm trocars for the surgeon’s working channel (one at the right subphrenic area and the other at the right anterior axillary line). The procedure was initiated by dissecting Calot’s triangle carefully to expose the confluence of the cystic duct and the common hepatic duct (CHD). After the cystic artery was clipped and excised, the cystic duct was also clipped or ligated with threads to prevent the passage of any gallbladder stones into the CBD during manipulation. Hartman’s pouch of the gallbladder was grasped and retracted superiorly and laterally by the first assistant to facilitate the dissection of Calot’s triangle. When the confluence of the cystic duct and the CHD was sufficiently exposed, a V-shaped incision was made using electrocautery along the medial wall of the cystic duct and the lateral wall of the CHD, which comprise two sides of Calot’s triangle (Fig. 1). The length of the incision was determined according to the size of the CBD stones. The choledochoscope was introduced via a 5-mm subxiphoid trocar and inserted into the lumen of the CBD through a V-shaped incision (Fig. 2). All stones in the lumen of the CBD were retrieved using a wire basket, Fogarty balloon catheter, saline irrigation with suction, or direct manipulation with atraumatic forceps. In cases with a very large and compacted stone, such as case 1, we fragmented the stones using the stone forceps through the V-shaped incision and then retrieved the fragments. During the procedure, lap-gauze was placed at Morrison’s pouch to prevent the spillage of extracted stones. To confirm the clearance of the CBD, the choledochoscope was passed downwards and advanced to just proximal to the ampulla of Vater (AOV). CBD clearance can be adequately confirmed by exploring the CBD up to the entrance of the AOV (without entering the AOV, which may help to prevent postoperative morbidity, including postoperative pancreatitis). The lumen of the ascending CBD was also assessed for the absence of remnant stones by moving the choledochoscope upward. The choledochotomy was closed using the bard absorbable suture material V-loc, a 4–0 absorbable wound closure device (V-Loc TM , Covidien, USA) that prevents loosening of the knot. After confirmation of CBD patency, the posterior side of the incision (composed of the posterior edge of the cystic duct and the CHD) was first closed in a continuous manner. For the first knot (made by passing the needle through the ring), the suture was placed so that the ring was outside the lumen, decreasing the risk of developing turbulent bile flow due to intra-luminal foreign material, which could cause stone recurrence. Subsequently, the anterior side of the incision was closed in the same manner. A schematic diagram of this closure is described in Fig. 3. After completion of the choledochotomy closure, the cystic duct was divided, and then standard LC was performed. The gallbladder and the extracted stones were bagged and retrieved through the umbilical trocar site. A closed suction drain was inserted through a lateral 5-mm trocar and placed in Morrison’s pouch. The drain was removed on the 2 nd postoperative day, as long as the drainage was <50 ml/day and free of bile. Patients returned to the outpatient department at the 7 th day after discharge, at which time we evaluated their general condition.
With advances in laparoscopic techniques and instruments, laparoscopic CBD exploration (LCBDE) has been performed more frequently, and there have been many reports that laparoscopic choledocholithotomy is less invasive than open surgery [5, 6]. However, in some patients with a narrow CBD, LCBDE is associated with a high risk of postoperative CBD stricture and bile leakage due to technical difficulty. To prevent these complications, surgeons have inserted T-tubes during LCBDE; however, T-tube insertion is nevertheless associated with complications, including infections that ascend through the drain, dislocation of the T-tube (which results in bile leakage), and most importantly, patient inconvenience due to prolonged T-tube placement . Surgeons have proposed a variety of techniques for laparoscopic choledocholithotomy [1, 6, 8–10], although there remains no consensus as to the best surgical treatment method.
This report suggests that our novel technique, known as V-CBD, may represent a feasible and straightforward procedure for treating choledocholithiasis, especially when the CBD is not dilated.
Since December 2013, ten patients have undergone LCBDE using a V-shaped choledochotomy (V-CBD). After the confluence of the cystic duct and the CBD were exposed, a V-shaped incision was made along the medial wall of the cystic duct and the lateral wall of the common hepatic duct, which comprise two sides of Calot’s triangle. The choledochoscope was inserted into the lumen of the CBD through a V-shaped incision, and all CBD stones were retrieved using a basket or a Fogarty balloon catheter or were irrigated with saline. After CBD clearance was confirmed using the choledochoscope, the choledochotomy was closed with the bard absorbable suture material known as V-loc.
The diameter of the CBD ranged from 8 to 30 mm, and the mean size of the stones was 11.6 ± 8.4 mm. The mean operative time was 97.8 ± 30.3 min, and the mean length of the postoperative hospital stay was 6.0 ± 4.6 days. All patients recovered without any postoperative complications, except for one patient who developed postoperative pancreatitis. No conversions to laparotomy were observed, and there were no recurrent stones and no need of T-tube insertion.
All medical data were prospectively collected, including the following: demographic and clinical features (age, sex, American Society of Anesthesiologists (ASA) grade, body mass index (BMI) and preoperative laboratory results); disease characteristics (size and number of stones, diameter of the CBD and the presence of gallstone pancreatitis); and surgical outcomes (CBD clearance, operative time, conversion to laparotomy, length of postoperative hospital stay, postoperative morbidity and mortality). This study was approved by the ethics committee at our institution (Institutional Review Board of Seoul St. Mary’s hospital, College of Medicine, the Catholic University of Korea, IRB code: KC14RISI0814) and all the patients provided their informed consent for the publication of this study.
Since December 2013, a total of 10 patients who were diagnosed with concomitant choledocholithiasis and cholelithiasis have undergone surgery using the novel technique of V-CBD at the Department of Surgery, Seoul St. Mary’s Hospital. In patients with concomitant cholelithiasis and choledocholithiasis, the treatment paradigm at our center is to initially perform ERCP to treat the choledocholithiasis, which is then followed by laparoscopic cholecystectomy (LC). However, V-CBD has been selectively used in patients who are not candidates for ERCP (due to conditions such as a history of total gastrectomy, periampullary diverticulum, large and impacted stones, or unavailability of ERCP equipment or endoscopists). Preoperative diagnosis was confirmed according to clinical features, laboratory results and radiologic tests including magnetic resonance cholangiopancreatography or computed tomography (CT) scan. In patients with septic shock or who had findings indicating the progression of biliary sepsis (such as delirium or uncontrollable fever despite antibiotic treatment), patients were diagnosed as having acute cholangitis and were initially managed with conservative treatment and resuscitated before any intervention. If patients were felt to be surgical candidates, V-CBD was used regardless of the size or number of stones and the history of previous upper abdominal operations.
The aim of this article is to describe our novel technique for LCBDE, which we have termed ‘laparoscopic CBD exploration through a V-shaped choledochotomy (V-CBD).’ This novel approach may help to overcome the limitations of conventional LCBDE for the surgical treatment of choledocholithiasis.
Surgical common bile duct (CBD) exploration is one of the treatment modalities for choledocholithiasis, which is the second most common complication of cholelithiasis, occurring in approximately 10–15 % of cholelithiasis patients [1, 2]. This approach has advantages over endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST), which is a widely used treatment for choledocholithiasis but carries a significant risk of complications such as acute pancreatitis, duodenal perforation, bleeding, and, importantly, iatrogenic injury to the muscles of the sphincter of Oddi [3, 4].
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Of 690 open cholecystectomies performed during the study period, 108 had common bile duct exploration. In 94 cases this was done via a supraduodenal choledochotomy, in 10 cases via a transduodenal sphincteroplasty and in 4 cases via the cystic duct. In 90 cases, a simple choledochotomy and primary closure was done while in 4 cases choledocho-duodenostomy was required. Eighty-seven percent of surgeries were done on elective basis and 13% on an emergency basis and no T-tubes were used in any patients. The mean hospital length of stay was 3.2 days and the perioperative morbidity was negligible.
A retrospective chart review of all consecutive open CBD exploration done by the first author over a period of 23 years was conducted. Demographic data, preoperative investigations, the surgical techniques and perioperative outcomes were recorded.
Despite advancements in gallbladder surgery with the introduction of endoscopic and laparoscopic techniques, many surgeons, especially in the developing world, still perform open cholecystectomy with common bile duct (CBD) exploration for choledocholithiasis. The purpose of the study is to report the outcomes of a case series of open CBD exploration without the use of T-tubes.
In a limited resource setting, there is still a role for open CBD exploration and primary closure without the necessity of T-tubes and stents as evidenced by a good perioperative patient outcome.
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