The authors have no acknowledgments.

The protocol was performed in accordance with the ethical guidelines of the University of Malaya Medical Center. Written consent was obtained, and a detailed explanation of the procedure was provided to the patient. Permission was also granted to produce the video of the procedure for educational purposes.
1. Positioning and sedation
<ol>
	<li>Place the patient in a prone position. Provide moderate sedation using intravenous infusion of Propofol. Ensure the infusion is titrated by the anesthetist.</li>
</ol>
2. Identifying the suitable target dilated left intrahepatic ducts
<ol>
	<li>Advance the linear echoendoscope making sure it passes the gastro-esophageal junction.</li>
	<li>Place the tip of the echoendoscope at the lesser curvature of the gastric cavity and proceed to identify the dilated left intrahepatic duct (IHD).</li>
	<li>Perform fluoroscopic imaging to ascertain the position of the echoendoscope. The tip of the echoendoscope must be placed at the lesser curvature of the gastric cavity, as stated previously. Always maintain the echoendoscope position and stabilize with periodic checks using fluoroscopic imaging throughout the procedure.</li>
	<li>Identify the dilated segment 3 IHD. Slightly tilt the angle of the tip of the echoendoscope upward to facilitate the next step in needle puncture. 
	&#8203;NOTE: Subsequent steps of the procedure involve inserting and exchanging of accessories via the working channel of the echoendoscope throughout the procedure.</li>
</ol>
3. Needle access into the targeted dilated left intrahepatic duct
<ol>
	<li>Perform Doppler ultrasound to ensure that there are no intervening blood vessels around the targeted IHD.</li>
	<li>Using a 19 G needle, puncture the segment 3 IHD (Figure 2A). Using a 10 mL syringe preloaded with 7 mL of the contrast solution, gently aspirate the bile solution, this was to confirm the success of biliary access.</li>
	<li>Following that, perform contrast injection to opacify the left IHD and the rest of the biliary system.</li>
</ol>
4. Guidewire manipulation
<ol>
	<li>Use a 0.025-inch guidewire to navigate into the left IHD under the fluoroscopic guidance.</li>
	<li>Cannulate the guidewire across into the right intrahepatic duct (Figure 2B). 
	&#8203;NOTE: Ideally, the guidewire should be manipulated deep into the common bile duct; however, it was not possible in this case due to the obstructing hilar tumor.</li>
</ol>
5. Fistula tract dilation
<ol>
	<li>Dilate the fistula tract using a 6 Fr electrocautery dilator in addition to using a 4 mm biliary balloon dilator (Figure 2C). 
	NOTE: Fistula tract dilation is required to facilitate insertion of the biliary stent later.</li>
	<li>Perform balloon inflation for approximately 5 s. 
	NOTE: While doing these, monitor the position of the accessories monitored using both the sonographic and fluoroscopic image, ensuring that the wire is visible and the echoendoscope position is maintained. This is done to ensure a smooth transition during the exchange of accessories which is very important.</li>
</ol>
6. Stent insertion and deployment
<ol>
	<li>Deploy a 10 mm sized partially covered biliary stent (length of 10 cm) under fluoroscopic guidance (Figure 3A). 
	NOTE: The stent has a 3 cm uncovered distal portion and a 7 cm covered proximal portion. The uncovered part must be within the intrahepatic duct (Figure 3C). Approximately 3 cm of the covered part of the stent is left in the gastric cavity to prevent inward migration of the stent (Figure 3B).</li>
	<li>Ensure that the distal end of the stent opens in the IHD. Deploy the proximal end within the working channel of the echoendoscope and subsequently release into the stomach with bile seen flowing within the stent.</li>
</ol>

The authors have nothing to disclose.

The above case description illustrates the possibility of using EUS-HGS as an alternative biliary drainage method in the management of biliary tract malignancies compared to existing methods such as ERCP and PTBD. Among the steps described above, identifying, and accessing the correct intrahepatic duct, guidewire manipulation, and stent deployment are the three main crucial steps in ensuring that the procedure can be performed successfully and safely.
In choosing the ideal liver segment for bi...

Patients with malignant biliary obstruction are often unresectable and advanced at presentation1,2. As a result, palliative endoscopic biliary decompression is often needed in managing these cases3,4,5. According to current recommendations, Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary method of biliary drainage, whenever possible, and if this fails or is contraindicated, Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method6,7,8. However, there are certain complications associated with PTBD, which include septicemia, cholangitis, bleeding, electrolyte lost, leakage, wound infection, local discomfort; these complications are reported to be as high as 53.2%9. The emergence of Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method to address this gap. The principal technique of EUS-BD involves the use of endosonographic imaging to guide access to the biliary system via the gastrointestinal tract to provide therapeutic decompression of an obstructed biliary system.
EUS-BD was first performed in 2001, and since then, this method of biliary drainage has evolved over the years10. Methods of EUS-BD commonly are EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided Anterograde stenting (EUS-AS), and EUS-guided Rendezvous (EUS-RV)11,12. To date, the indications for EUS-BD include patients who have failed ERCP, patients having an inaccessible papilla by duodenal obstruction, and patients with altered surgical anatomy13,14,15.
EUS-HGS involves transmural drainage of the left intrahepatic duct into the stomach. The main advantage is that it provides internal drainage, which is more physiological and, most of all, offers better patients&#39; comfort compared to PTBD12,16. This method is feasible for both hilar and distal malignant biliary obstruction. Here, we describe the technique of EUS-HGS as one of the methods of EUS-BD in a case of unresectable malignant hilar tumor.
A 71-year-old female was presented with painless jaundice and had a weight loss of 4 kg in 2 weeks duration. On examination, she was found to have scleral jaundice. Abdominal examination was unremarkable. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor involving the bifurcation of the right hepatic duct, the confluence of hepatic ducts and extrahepatic ducts, causing marked intrahepatic duct dilatation with lymphadenopathy and liver metastasis (Figure 1A). EUS fine needle biopsy (FNB) of the lesion was performed and it showed adenocarcinoma with positive CK7 and CA19-9 which was consistent with the diagnosis of hilar cholangiocarcinoma (Figure 1B). Her bilirubin levels were 212 &#181;mol/L (&#60;15) at presentation and CA19-9 levels were 305 U/mL. EUS-HGS was performed to provide relief in the biliary obstruction.

<table><tbody><tr><td>10mm in size, 10cm in length Partially Covered Metallic Stent</td><td>M.I Tech</td><td>BPD10100-E180</td><td></td></tr><tr><td>Curved Linear Echoendoscopy</td><td>Fujifilm</td><td>EG-580UT</td><td></td></tr><tr><td>Electrocautary Dilator, 6Fr</td><td>G-Flex</td><td>CYSTO06U</td><td></td></tr><tr><td>Endoscopic Ultrasound System Processor</td><td>Fujifilm</td><td>SU-1</td><td></td></tr><tr><td>Expect 19-guage FNA Needle</td><td>Boston Scientific</td><td>M00555500</td><td></td></tr><tr><td>Hurricane Biliary Balloon Dilator, 4mm</td><td>Boston Scientific</td><td>M00545900</td><td></td></tr><tr><td>Visiglide 0.025-inch Guidewire, 4500mm in length</td><td>Olympus</td><td>G-240-2545S</td><td></td></tr></tbody></table>

endoscopic ultrasound-guided biliary drainage: endoscopic ultrasound-guided hepaticogastrostomy in malignant biliary obstruction

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary biliary drainage method whenever possible. Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method if ERCP fails. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method where one of the methods is EUS guided Hepaticogastrostomy (EUS-HGS). Here we describe the EUS-HGS technique in a case of unresectable malignant hilar biliary obstruction to achieve biliary drainage.
Presented here is the case of a 71-year-old female with painless jaundice and weight loss for 2 weeks. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor with lymphadenopathy and liver metastasis. EUS fine needle biopsy (FNB) of the lesion was consistent with cholangiocarcinoma. Her bilirubin levels were 212 &#181;mol/L (&lt;15) during presentation.
A linear echoendoscope was used to locate the left dilated intrahepatic ducts (IHD) of the liver. The segment 3 dilated IHD was identified and punctured using a 19 G needle. Contrast was used to opacify the IHDs under fluoroscopic guidance. The IHD was cannulated using a 0.025-inch guidewire. This was followed by the dilation of the fistula tract using a 6 Fr electrocautery dilator along with a 4 mm biliary balloon dilator. A partially covered metallic stent of 10 cm in length was deployed under fluoroscopic guidance. The distal part opens in the IHD and the proximal part was deployed within the working channel of the echoendoscope that subsequently released into the stomach. The patient was discharged three days after the procedure. Follow up performed in the second and fourth weeks showed that the bilirubin levels were 30 &#181;mol/L and 14 &#181;mol/L, respectively. This indicates that EUS-HGS is a safe method for biliary drainage in unresectable malignant biliary obstruction.

The procedure was completed in approximately 30 min. There were no complications after the procedure and the patient was able to resume oral intake the next day. The bilirubin levels fell to 92 &#181;mol/L and she was discharged three days after the procedure. A repeated CT imaging was done which showed the stent in position with a resolution of biliary obstruction. The bilirubin level on the follow-up was 30 &#181;mol/L after 2 weeks post procedure and 14 &#181;mol/L at 4 weeks post procedure (Table 1)....

Watch this Scientific Journal Video about Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction at JoVE.com

Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction

Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) is an alternative method of biliary decompression in malignant biliary obstruction. Here we describe the technique of EUS guided-Hepaticogastrostomy (EUS-HGS) in a case of unresectable malignant hilar biliary obstruction.

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde ...

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5.6K Views.  University of Malaya. Endoscopische echografie-geleide galdrainage: Endoscopische echografie geleide hepaticogastrostomie bij maligne galwegobstructie. Patiënten met kwaadaardige galwegobstructie zijn vaak niet-reseceerbaar en gevorderd bij presentatie. Palliatieve endoscopische galdecompressie is vaak nodig bij het beheersen van deze gevallen.ERCP is de primaire methode van galdrainage waar mogelijk en als dit faalt of gecontra-indiceerd is, wordt PTBD gebruikt als een bergingsmethode. Complicaties geasso...

Video: Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction

A Two-Step Method for Percutaneous Transhepatic Choledochoscopic Lithotomy

Intrahepatic and extrahepatic choledocholithiasis is a challenge in the field of biliary surgery. We present our experience using a two-step percutaneous transhepatic choledochoscopic lithotomy (PTCSL) procedure to treat challenging biliary stones. We retrospectively reviewed 81 patients with intrahepatic and extrahepatic choledocholithiasis treated using this two-step PTCSL from January 2013 to January 2020, including 40 males and 41 females, with an average age of 66 years. In contrast to traditional percutaneous transhepatic cholangioscopy (PTCS), a channel was established directly through a 16F Amplatz sheath, and the stone in the channel was removed with the aid of a nephroscope. The clinical efficacy and complications of all patients were analyzed. Eighty-one patients (81/81, 100%) had their biliary stones successfully removed; 62/81 patients (76.5%) had biliary stones completely removed after the first operation; 17/81 patients (21%) underwent a second operation; 2/81 patients (2.5%) needed a third operation to completely remove the stones. The incidence of severe bleeding during the operation was 0%, and there were no deaths. The use of the two-step PTCSL method is safe and efficacious, and contributes to a better prognosis of intrahepatic and extrahepatic choledocholithiasis.

This "two-step method" significantly improved the success rate of percutaneous transhepatic choledochoscopy and achieved a better prognosis of intrahepatic and extrahepatic choledocholithiasis.

Intrahepatic and extrahepatic choledocholithiasis is a challenge in the field of biliary surgery. We present our experience using a two-step percutaneous ...

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In this study, a 32-year-old male patient with Bismuth Type IVa hilar cholangiocarcinoma underwent radical robotic resection of hepatic S4b, S5, and S1 (Taj Mahal hepatectomy) combined with regional lymphadenectomy, hilar bile duct reconstruction, and hepaticojejunostomy by the robotic surgical system. Postoperative pathological examination showed moderately-differentiated adenocarcinoma of the hilar bile duct. The surgical margins of the liver and bile ducts were negative. Recovery was smooth and the patient was discharged on the 17th postoperative day. The robotic surgical system and associated multiple instruments along with flexible and precise movements is suitable for the local hepatectomy around the porta hepatis, and delicate reconstruction of the hilar bile duct with a smaller diameter. This first clinical application study found that robotic Taj Mahal hepatectomy for hilar cholangiocarcinoma is safe and feasible and needs more experience for the evaluation of its long-term outcomes.

Robotic resection of hepatic S4b, S5, and S1 using the Taj Mahal procedure is feasible and safe for selected patients with hilar cholangiocarcinoma. The step-by-step details for this surgery are presented here.

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...

Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs easily when performing another operation for laparoscopic common bile duct exploration (LCBDE), which was once considered a relative contraindication. In view of the limitations of the current surgical technique, this study summarized the surgical approaches and crucial anatomical landmarks for reoperation for LCBDE. Four general surgical approaches were proposed to expose the common bile duct, including the ligamentum teres hepatis approach, the anterior hepatic duodenal ligament approach, the right hepatic duodenal ligament approach, and the hybrid approach. Additionally, this study highlighted seven crucial anatomical landmarks: the parietal peritoneum, the gastrointestinal serosa, the ligamentum teres hepatis, the inferior margin of the liver, the gastric antrum, the duodenum, and the hepatic flexure of the colon, which were helpful to safely separate abdominal adhesions and expose the common bile duct. Moreover, to shorten the time of choledocholithotomy, a sequential method was innovatively applied for the removal of the stones in common bile duct. Mastering the above surgical approaches, including identifying crucial anatomical landmarks and adopting the sequential method will improve the safety of reoperation for LCBDE, shorten the operation time, promote the fast recovery of patients, reduce postoperative complications, and contribute to the popularization and application of this technique.

Programmed surgery based on surgical methods and anatomical markers helps shorten the operation time, reduce complications, and improve the safety of the surgery. This study investigated and summarized the surgical methods and anatomic markers of laparoscopic common bile duct exploration in patients with a history of biliary tract surgery.

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs ...

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH.
The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before.
Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

Here, we present a protocol to perform a modified laparoscopic anatomic hepatectomy using improved techniques and instruments.

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to ...

Application of Robot-assisted Pancreaticobiliary Junction Resection in Benign Duodenal Tumors

Robot-assisted pancreaticobiliary junction resection is a surgical technique employed to treat benign duodenal tumors. The procedure involves several key steps: making a longitudinal incision in the duodenum, excising the tumor at the pancreaticobiliary junction, inserting a biliary stent, connecting the biliary and duodenal mucosa, and suturing the duodenal incision during phase I. The robotic system enhances visibility, facilitates precise operations, minimizes duodenal traction injuries to the duodenum and surgical trauma, ensures accurate suture and fixation of bile duct stents, connects the bile duct and duodenal mucosa and reduces postoperative recovery time. Given the complexity of the operation and the associated risk of postoperative duodenal fistula, a thorough preoperative evaluation and meticulous perioperative preparation are crucial. Prior to the procedure, a comprehensive assessment was conducted, integrating the patient's medical history, family history, serological tests, and imaging studies. Special emphasis was placed on determining the benign or malignant nature of the tumor and evaluating the status of the duodenal artery blood supply network to ascertain the feasibility and efficacy of the surgery. During the operation, efforts were made to minimize duodenal trauma and avoid compromising the duodenal artery blood supply network. Additionally, the use of bile duct stents was considered essential to prevent biliary strictures, facilitate bile discharge, and mitigate biliary complications. Postoperatively, real-time monitoring of amylase and jaundice indicators in drainage fluid informed the timely removal of drainage tubes in accordance with the enhanced recovery after surgery (ERAS) protocol. Subsequent follow-up indicated a successful recovery, characterized by a notable reduction in preoperative abdominal pain, the absence of long-term complications, and no evidence of tumor recurrence. Consequently, robot-assisted pancreaticobiliary junction resection demonstrates a safe and effective surgical approach for the treatment of benign duodenal tumors.

The current protocol delineates the use of robot-assisted pancreaticobiliary junction resection for the surgical management of benign duodenal tumors. This approach provides an effective solution for treating these tumors while minimizing duodenal loss and reducing associated complications.

Robot-assisted pancreaticobiliary junction resection is a surgical technique employed to treat benign duodenal tumors. The procedure involves several key ...

Gastroscope-assisted Trans-Trocar Gastrostomy and Abdominal Exploration

Advanced endoscopic technologies have revolutionized gastrointestinal surgical procedures, transitioning from open or laparoscopic methods to endoscopic interventions. Gastrostomy is a classic clinical technique for patients with swallowing impediments due to obstructions in the cardiac or esophageal regions and has evolved significantly with the establishment of percutaneous endoscopic gastrostomy (PEG). While PEG offers reduced trauma and swift recovery, it falls short of exploratory capabilities and risks damaging adjacent organs. Therefore, we developed an innovative approach-gastroscope-assisted trans-Trocar gastrostomy (GTTG), which not only takes full play to the advantages of PEG with less trauma and faster postoperative recovery but also takes into account the advantages of laparoscopic gastrostomy with a good exploration of the abdominal cavity. This technique is characterized by ease of operation, minimal trauma (including short operation time and no redundant incision), rapid recovery, the ability to explore the abdominal cavity, and avoidance of injury to adjacent organs, which is quite worthy of widespread promotion in clinical settings.

Here, we introduce a novel technique of gastrostomy, which integrates laparoscopic and gastroscopic techniques, offering a streamlined approach with reduced invasiveness, expedited recovery, and the capacity for abdominal exploration while minimizing the risk of adjacent organ injury.

Advanced endoscopic technologies have revolutionized gastrointestinal surgical procedures, transitioning from open or laparoscopic methods to endoscopic ...

Establishment of an Animal Training Model of Duodenoscopy, Choledochoscopy, and Laparoscopy for Cholelithiasis

Cholelithiasis is a condition characterized by the formation of stones in the gallbladder and/or bile ducts. Proficient use of duodenoscopy, laparoscopy, and choledochoscopy techniques plays a pivotal role in managing cholelithiasis. To enhance young doctors&#39; proficiency in multiendoscope technology application, a training model for duodenoscopy, choledochoscopy, and laparoscopy was established using a live pig model. Initially, the duodenoscope was used to access the duodenum through passage through the mouth, esophagus, and stomach to observe the duodenal papilla. Subsequently, the tube was inserted into the common bile duct, followed by the placement of the guide wire. Trocars were subsequently inserted to establish pneumoperitoneum and facilitate the performance of laparoscopic cholecystectomy. The common bile duct was explored and opened with the retrieval of the guide wire found within it. The choledochoscope was then used to explore both distal common bile duct and intrahepatic bile ducts. Finally, under duodenoscopy guidance, either nasobiliary tube or plastic biliary stent placement occurred before primary suture closure of the common bile duct. Establishing a multi-scopy combined animal model can further enhance young doctors&#39; proficiency in multi-scopy combined technology through practical experience.

Here, we present a protocol for establishing a multi-scopy combined animal training model to enhance the proficiency and comprehension of young doctors in multi-scopy combined technology.

Cholelithiasis is a condition characterized by the formation of stones in the gallbladder and/or bile ducts. Proficient use of duodenoscopy, laparoscopy, ...

Application of Laparoscopic Ultrasonography in Primary Choledochal Suture during Combined Two-lens Surgery

Gallstones combined with common bile duct stones are a common clinical disease. The minimally invasive treatments include laparoscopic cholecystectomy + laparoscopic common bile duct exploration (LC+LCBDE) and endoscopic retrograde cholangiopancreatography + laparoscopic cholecystectomy (ERCP+LC). LCBDE can resolve two issues in a single procedure, whereas ERCP+LC requires a two-step approach. As more studies have shown, common bile duct exploration with stone extraction followed by primary closure may lead to faster recovery and improved quality of life for patients.
Anatomical variations in bile ducts and vessels are well-known to be common. Laparoscopic ultrasound (LUS) is instrumental in clarifying the hepatic portal area's anatomical structures, determining biliary duct orientation, identifying spatial relationships between biliary ducts, hepatic arteries, and portal veins, and minimizing the risk of biliary injury.
The procedure is illustrated here through a detailed case description. After administering general anesthesia, a laparoscopic approach was routinely established to inspect the abdominal cavity and assess lesions. Laparoscopic ultrasound was employed to evaluate the gallbladder triangle within the hepatic portal region, including the anatomy of bile ducts and vessels. The gallbladder triangle was dissected, followed by a 5-0 needle incision of the bile duct wall. Choledochoscopy was performed for stone extraction, with confirmation of normal duodenal papillary function. Continuous suturing of the bile duct wall was achieved using 5-0 polydioxanone monofilament suture material. Concurrently, laparoscopic ultrasound verified complete stone clearance and assessed suture integrity.

Here, we develop and present a T-tube and intrabiliary stent-free technique utilizing dual-lens visualization (via laparoscope and choledochoscope) combined with laparoscopic ultrasonography (LUS) to perform primary choledochal suture.

Gallstones combined with common bile duct stones are a common clinical disease. The minimally invasive treatments include laparoscopic cholecystectomy + ...

Novel Treatment for Complex Bile Leakage After Liver Transplantation

Bile leakage is a common complication after liver transplantation that may usually be cured with endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangial drainage (PTCD), percutaneous transhepatic cholangioscopy (PTCS)and surgery. We report a novel treatment for biliary leakage lasting 9 months after liver transplantation, during which ERCP, PTCD, PTCS, and surgical therapy were in vain. We have used a new method of multi-endoscopic treatment. First, ERCP and peroral single operator cholangioscopy are used to place a plastic stent as a marker at the distal end of the bile leakage site. Second, PTCS is performed through the PTCD tube. During the operation, the proximal end of the bile leakage site is located by the plastic stent and B ultrasound, and the continuity of the biliary tract is temporarily reconstructed through the guide wire and urinary catheter. Third, a double-headed guidewire is placed, the urinary catheter is removed, the stents are placed, and biliary continuity is reconstructed. In conclusion, we have found a new method combining ERCP, peroral single operator cholangioscopy, and PTCS to treat complex bile leakage after liver transplantation.

Bile leakage is a common complication after liver transplantation that significantly affects patients' prognosis. The protocol presents a new method of combining endoscopic retrograde cholangiopancreatography (ERCP), branch choledochoscope, and percutaneous transhepatic cholangioscopy (PTCS) for treating complex bile leakage after liver transplantation.

Bile leakage is a common complication after liver transplantation that may usually be cured with endoscopic retrograde cholangiopancreatography (ERCP), ...

Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction

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