This work was supported by grants from the Medical Scientific Research Foundation of Guangdong Province (No. A2021091), the Fundamental Research Funds for the Central Universities (No. 21622312), the Basic and Applied Basic Research Project of Guangzhou Basic Research Program (No. 2023A04J01111), the Flagship Specialty Construction Project-General Surgery of the First Affiliated Hospital of the Jinan University (No. 711003), and the Special Foundation for Scientific Research Development of the Affiliated Shunde Hospital of Jinan University (No. 202101004).

A total of 177 patients with a history of biliary tract surgery who underwent LCBDE between September 2010 and December 2021 were included. This study was approved by the institutional review board in The First Affiliated Hospital of Jinan University. All patients provided written informed consent.
1. Inclusion criteria
<ol>
	<li>Include patients with more than two stones in the common bile duct (CBD).</li>
	<li>Include patients with CBD stones that have a total diameter of &#8805;20 mm.</li>
	<li>Include patients with a CBD diameter of &#8805;10 mm.</li>
</ol>
2. Exclusion criteria
<ol>
	<li>Exclude patients with hepatolithiasis.</li>
	<li>Exclude patients with acute obstructive suppurative cholangitis.</li>
	<li>Exclude patients with a Child-Pugh liver function of class B or class C.</li>
	<li>Exclude patients with scheduled simultaneous biliary anastomosis.</li>
	<li>Exclude patients with an intolerance to general anesthesia due to a poor general condition.</li>
</ol>
3. Preoperative preparation
<ol>
	<li>Administer preoperative blood tests including a complete blood count, liver and renal function test, and coagulation function test.</li>
	<li>Administer preoperative hepatobiliary color Doppler ultrasound, upper abdominal computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP).</li>
</ol>
4. Establishment of pneumoperitoneum and trocar placement under general anesthesia with tracheal intubation
<ol>
	<li>Use a Veress needle to establish pneumoperitoneum routinely (Veress method)11.
	<ol>
		<li>Make a 10 mm long incision on the skin below the umbilicus, then clamp and lift up the skin on both sides of the incision. Insert the Veress needle into the abdominal cavity through the incision. Then, inject carbon dioxide gas and maintain a pneumoperitoneum pressure of 12 mmHg.</li>
	</ol>
	</li>
	<li>If the Veress method fails, change to the open method (Hasson method)11.
	<ol>
		<li>Using the conventional laparotomy method, incise the abdominal wall layer by layer to the depth along the skin incision made by the Veress method to reach the abdominal cavity. Place the observation port into the abdominal cavity through this incision. Inject carbon dioxide gas and maintain a pneumoperitoneum pressure of 12 mmHg.</li>
	</ol>
	</li>
	<li>Place the observation port (the first trocar) around the umbilicus as far as possible to fully explore the abdominal cavity. At the same time, keep the first trocar at least 5 cm away from the previous open incision, or at least 2 cm away from the previous laparoscopic incision, to avoid damage to the intestine adhered to the abdominal wall.</li>
	<li>According to the adhesion situation observed in abdominal cavity exploration, arrange the trocars typically in a triangular shape with the surgical area as the target. At the same time, take the separation of adhesions, choledochoscopic lithotomy, and T-tube and drainage tube indwelling into consideration.</li>
</ol>
5. Surgical approaches
<ol>
	<li>Hepatic round ligament approach: Separate and release the abdominal adhesions along the hepatic round ligament to the inferior liver margin, and then to the hepatic hilum in order to expose the CBD.</li>
	<li>Anterior hepatoduodenal ligament approach: Separate the duodenum from the hepatic hilum downward to expose the CBD anterior to the hepatoduodenal ligament.</li>
	<li>Right hepatoduodenal ligament approach: Separate the hepatic flexure of the colon, adhered to the hepatic hilum, from the hepatic hilum, starting from the right lateral side of the hepatoduodenal ligament downward to expose the area between the right subhepatic space and the omental foramen, thereby determining the position of the CBD.</li>
	<li>Hybrid approach: Combine two or three of the above approaches. 
	NOTE: This mainly depends on the location of adhesion.
	<ol>
		<li>If there is adhesion in the middle of the anterior abdominal wall, use the hepatic round ligament approach.</li>
		<li>If there is adhesion in the front and on both sides of the CBD, use the anterior hepatoduodenal ligament approach.</li>
		<li>If there is adhesion in the right upper abdomen, use the right hepatoduodenal ligament approach.</li>
		<li>If there is extensive adhesion in the abdominal cavity, use the hybrid approach. The hybrid approach is the most commonly used method in this study.</li>
		<li>Use the above three approaches flexibly and alternately, and start the separation from near to far, from simple to complex, and from loose tissues to adhered and dense tissues.</li>
	</ol>
	</li>
</ol>
6. Adhesion separation and CBD exposure based on anatomical landmarks
<ol>
	<li>Parietal peritoneum and gastrointestinal serosa: Use noninvasive grasping forceps to clamp and pull the gastrointestinal tract adhering to the abdominal wall with appropriate traction tension, and separate and release the adhesions close to the parietal peritoneum and away from the gastrointestinal serosa.
	<ol>
		<li>Separate the loose adhesions with a blunt dissection or ultrasonic scalpel, and release the dense adhesions or adhesions involving intestines with scissors to avoid thermal damage (Figure 1).</li>
	</ol>
	</li>
	<li>Hepatic round ligament: In patients with a history of biliary tract surgery, there are often mutual adhesions between the gastric antrum, duodenum, liver, and abdominal wall. Find the inferior liver margin by separating the adhesions upward along the hepatic round ligament, and expose the gastric antrum and the duodenum (Figure 2 and Figure 5).</li>
	<li>Inferior liver margin: After exposing the inferior liver margin through the hepatic round ligament, separate the adhesions downward along the visceral surface of the liver, and further expose the gastric antrum and the duodenum. Separate the adhesions at this location close to the liver, under the principle of injuring the liver rather than the gastrointestinal tract if injury is unavoidable (Figure 3, Figure 4, and Figure 5).</li>
	<li>Gastric antrum and duodenum: The gastric antrum and the first and second segments of the duodenum tend to move up and seal the first hepatic hilar region through adhesions. Separate the adhesions downward along the visceral surface of the liver from the inferior liver margin and expose the gastric antrum and duodenum. Then, lower the gastric antrum and duodenum to further expose the CBD (Figure 4, Figure 5, and Figure 6).</li>
	<li>Hepatic flexure of the colon: Separate the adhesions between the omentum, intestine, and abdominal wall of the right upper abdomen, and find the hepatic flexure of the colon. Separate and lower the hepatic flexure of the colon from the right inferior liver margin. Expose the CBD by separating the adhesions from the right subhepatic space to the omental foramen (Figure 3).</li>
</ol>
7. Sequential lithotomy
<ol>
	<li>Laparoscopic lithotomy with forceps: Push the lower segment of the CBD using noninvasive grasping forceps, and squeeze the large stones toward the incision of the CBD. Take out the stones directly using forceps.</li>
	<li>Laparoscopic lithotomy via blind basket extraction: Insert the stone basket into the CBD and open it. Then, pull the basket up and down repeatedly without choledochoscopic assistance. Take out the stones that cannot be squeezed toward the CBD incision via blind basket extraction, which substantially shortens the time of choledochoscopic lithotomy.</li>
	<li>Stone removal by flushing the CBD with saline: Insert a silicone tube into the CBD. Use a 50 mL syringe to inject saline into the CBD through the silicone tube and flush out the small stones.</li>
	<li>Choledochoscopic lithotomy: Insert the choledochoscope into the CBD, and continuously inject saline through the choledochoscope flushing channel. Put the stone extraction basket into the CBD through the instrument channel of the choledochoscope and open it, then take out the stones under the direct vision of the choledochoscope.</li>
	<li>Lithotripsy: According to the diameter of the CBD, insert the sheath of the nephroscope of appropriate size into the CBD through the abdominal puncture port. Then, insert the nephroscope into the common bile duct through the sheath, and continuously inject saline.
	<ol>
		<li>Perform pneumatic ballistic lithotripsy or holmium laser lithotripsy under the direct vision of the nephroscope.</li>
	</ol>
	</li>
</ol>
8. T-tube indwelling or CBD primary suture
<ol>
	<li>Primary suture the CBD for patients with a definite effect after lithotomy, a CBD diameter of &#8805;10 mm, and no evident stenosis of the lower segment of the CBD.</li>
</ol>

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The authors have nothing to disclose.

The most common cause of choledocholithiasis is stones falling into the CBD through the gallbladder, while some CBD stones can origin from the CBD itself1. The incidence rate of choledocholithiasis in patients after cholecystectomy is 10%-18%, and 4%-24% of patients with choledocholithiasis have recurrence after the first lithotomy and often require repeated surgery(ies)12,13. Since the first application of LCBDE in 1991, it has been prove...

Choledocholithiasis is one of the most common biliary tract diseases, with a high recurrence rate1. Because recurrent choledocholithiasis often involves multiple stones, coupled with the fact that endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) may damage the function of Oddi&#39;s sphincter as well as cause repeated retrograde biliary tract infections, patients with recurrent choledocholithiasis often require two or more surgical operations2.
With the popularization of minimally invasive surgery and the advancement of laparoscopic techniques, laparoscopic common bile duct exploration (LCBDE) has been widely used in clinical practice, thanks to such advantages as minimal trauma, rapid recovery, and preservation of the function of Oddi&#39;s sphincter3. Abdominal adhesions in patients with recurrent choledocholithiasis lead to changes in anatomical structure, so these patients are susceptible to a secondary injury in a subsequent bile duct exploration. Therefore, abdominal adhesions have been considered a contraindication of laparoscopic surgery4,5. With further technological development, LCBDE has been preliminarily confirmed to be feasible in patients with a history of biliary tract surgery6,7,8.
However, relevant studies have been limited, and more in-depth research into this surgical technique is still needed. Programmed operations for LCBDE are often lacking, especially for patients with extensive abdominal adhesions. Based on this situation, the present study aims to develop a programmed procedure by investigating the surgical approaches and anatomical landmarks of LCBDE in patients with a history of biliary tract surgery. A programmed operation based on surgical approaches and anatomical landmarks can help to shorten the operation, reduce complications, and improve surgical safety9,10.

<table><tbody><tr><td>Electronic choledochoscope</td><td>Olympus</td><td>CHF-V</td><td>/</td></tr><tr><td>Harmonic scalpel</td><td>Ethcion</td><td>HAR36</td><td>/</td></tr><tr><td>Stone basket</td><td>Cook</td><td>NTSE-045065-UDH</td><td>/</td></tr></tbody></table>

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.

This study included 177 patients (mean age: 61.74 &#177; 5.97 years), including 79 males and 98 females. A total of 69 patients had a history of open cholecystectomy (OC); 36 patients had a history of OC and open common bile duct exploration (OCBDE); eight patients had a history of OC, OCBDE, and left lobe hepatectomy (LLH); three patients had a history of OC, OCBDE, and choledochojejunostomy; 42 patients had a history of laparoscopic cholecystectomy (LC); seven patients had a history of LC and LCBDE; and 12 patients had...

Watch this Scientific Journal Video about Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery at JoVE.com

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

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 ...

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Research

JoVE Journal

Medicine

1.7K Views.  Jinan University. Dit protocol heeft tot doel een geprogrammeerde procedure te ontwikkelen door de chirurgische benaderingen en anatomische oriëntatiepunten van laparoscopische gemeenschappelijke galwegexploratie, of LCBDE, te onderzoeken bij patiënten met een voorgeschiedenis van galwegchirurgie. Een geprogrammeerde operatie op basis van chirurgische benaderingen en anatomische oriëntatiepunten kan helpen om de operatietijd te verkorten, complicaties te verminderen, de chirurgische veiligheid te verbeteren...

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

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.
The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index &#62;35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.
The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.
The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

Cancer Research

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic remnants to reduce the severity of postoperative pancreatic fistulas and moreover the overall postoperative morbidity. This reconstruction technique is characterized by an extra-long jejunal loop for the construction of the pancreaticojejunostomy and hepaticojejunostomy. The longer distance between these anastomoses and an additional jejuno-jejunostomy between the afferent and efferent limb of the hepaticojejunostomy separate the fluids and prevent backflow of bile towards the pancreaticojejunostomy. Thus, the secretions cannot activate each other and aggravate an existing anastomotic leakage. We observed a reduced rate of severe postoperative pancreatic fistulas after modified single-loop reconstruction compared to conventional single loop reconstruction. The technique is easy to perform, safe, and less time-consuming than a traditional double-loop reconstruction.

The technique of modified single-loop reconstruction following pancreaticoduodenectomy separates pancreatic secretion from bile, thus reducing the severity of POPF without prolonging the duration of surgery.

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic ...

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.

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 ...

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 ...

Laparoscopic Sectionectomy Using Ligamentum Teres for Bloodless Hepatectomy

Laparoscopic Left Lateral Sectionectomy: Guided by the Ligamentum Teres Hepatis and the Umbilical Fissure Vein

Laparoscopic left lateral sectionectomy (LLLS), a mainstream procedure in liver surgery, often utilizes controlled low central venous pressure (CLCVP) to reduce bleeding in the hepatic venous system. However, anesthesiologists may avoid the use of CLCVP in patients with concurrent cardiovascular and cerebrovascular diseases to prioritize the maintenance of vital organ perfusion. In this report, we present an LLLS guided by the ligamentum teres hepatis (LTH) for dissection of the Glissonian pedicles for segments 2/3 outside the liver, followed by hepatic parenchymal dissection along the falciform ligament and umbilical fissure vein (UFV) while approaching the left hepatic vein root. Guided by LTH and UFV, this LLLS procedure effectively controlled intraoperative bleeding, even in the absence of CLCVP. Additionally, hepatectomy guided by extrahepatic and intrahepatic anatomical landmarks prevents loss of direction during liver dissection and ensures precise hepatic resection. These attributes suggest that the potential benefits extend beyond patients with cardiovascular or cerebrovascular conditions, making it applicable in a wide range of LLLS cases.

Author Spotlight: Advancing Hepatobiliary and Pancreatic Tumor Treatment with Minimally Invasive Surgical Techniques

Laparoscopic left lateral sectionectomy guided by the ligamentum teres hepatis and umbilical fissure vein effectively controls intraoperative bleeding even without controlled low central venous pressure and prevents loss of direction during parenchymal dissection.

Laparoscopic left lateral sectionectomy (LLLS), a mainstream procedure in liver surgery, often utilizes controlled low central venous pressure (CLCVP) 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 ...

Complete Laparoscopic Radical Resection of Perihilar Cholangiocarcinoma Type IIIb

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With continuous advancements in laparoscopic techniques and instruments, laparoscopic radical surgery for pCCA is now considered technically safe and feasible. However, due to the high complexity of the surgery and the lack of evidence-based clinical support, laparoscopic radical surgery for type IIIb pCCA is performed only in a few large hepatobiliary centers. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA. Therefore, in this article, we provide a detailed description of the surgical steps and technical points of complete laparoscopic left hemihepatectomy combined with total caudate lobectomy, regional lymphadenectomy, and right hepatic duct-jejunal Roux-en-Y anastomosis in patients with type IIIb pCCA, using fluorescence navigation technology to enhance surgical precision and safety. By adhering to standardized surgical procedures and precise intraoperative techniques, we offer an effective means to improve patient outcomes.

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With ...

The Role of Indocyanine Green Fluorescence in Complex Laparoscopic Cholecystectomy Navigation

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for cholelithiasis and cholecystitis. In difficult cases with severe inflammation and adhesions, the risk of bile duct injury (BDI) is significantly higher. Precise identification of anatomical biliary structures is essential to prevent such injuries. Conventional intraoperative visualization techniques (IVT) have limited clinical application due to their complexity, increased trauma, and high error rates. Near-infrared fluorescence (NIRF) imaging, utilizing indocyanine green (ICG) as a fluorescent dye, has emerged as an innovative IVT technique. It is increasingly recognized as a feasible, safe, and effective approach for LC. However, the efficacy of NIRF in difficult LC procedures remains unclear, and the optimal timing and dosage of ICG administration are yet to be established. This article outlines the main steps for performing fluorescence-guided difficult LC in a patient with acute gangrenous cholecystitis and evaluates the imaging effects of NIRF in various scenarios. The patient was positioned supine, with four trocars placed. Upon switching to fluorescence mode, the fluorescently labeled bile ducts were readily identified. Following fluorescence guidance, Calot's triangle was carefully dissected. The cystic duct (CD) and cystic artery (CA) were individually identified and clipped before the gallbladder was extracted. Finally, the surgical field was inspected in fluorescence mode to detect bile leakage. With satisfactory ICG imaging and a smooth procedure, the patient's postoperative recovery was uneventful. NIRF is a safe and effective technology that shows great promise for future clinical applications.

This protocol outlines the steps for fluorescence-guided laparoscopic cholecystectomy and elucidates the role of fluorescence navigation in diverse surgical scenarios.

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for cholelithiasis and cholecystitis. In difficult cases with severe inflammation and ...

Laparoscopic Choledochal Cyst Excision and Roux-en-Y Choledochojejunostomy in Adults

Choledochal cysts (CCs), known as congenital choledochal dilatations, are more prevalent in Asia. The majority of patients with abdominal symptoms are diagnosed and treated during early childhood, which results in a lower prevalence of CCs in adults. The treatment of choice for CCs is complete cyst excision followed by choledochojejunostomy. Laparoscopic surgery is now more widely accepted than traditional open surgery due to its smaller incisions, faster recovery, and less postoperative pain. However, there are few reports on laparoscopic excision of CCs in adults. This article presents a protocol that describes and demonstrates the complete procedure for laparoscopic excision of a choledochal cyst and Roux-en-Y choledochojejunostomy. A 32-year-old woman diagnosed with a 2.5 cm by 3 cm CC underwent surgery using a laparoscopic approach with post-colonic anastomosis. The procedure lasted 290 min with an estimated blood loss of approximately 100 mL. A follow-up abdominal CT scan on the sixth postoperative day showed a satisfactory recovery, leading to her discharge on the ninth day. This study aims to demonstrate the feasibility and safety of laparoscopically assisted excision of CCs in adults. This procedure is expected to become the preferred surgical option for CCs in adults due to its minimal surgical trauma and rapid postoperative recovery.

Choledochal cysts in adults are relatively rare, and few reports have detailed treatment options. Here, we present a case demonstrating laparoscopic resection of choledochal cysts and posterior colonic Roux-en-Y choledochojejunostomy in adults, offering an alternative for clinical management.

Choledochal cysts (CCs), known as congenital choledochal dilatations, are more prevalent in Asia. The majority of patients with abdominal symptoms are ...

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, ...

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

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