The study was approved by the Ethics Committee of the Second Affiliated Hospital of Shantou University Medical College (Shantou, China).
1. Preparations
<ol>
	<li>Apply strict exclusion criteria to select patients and obtain signed informed consent forms12 (Table 1).</li>
	<li>Apply the following admission criteria:
	<ol>
		<li>Select patients who voluntarily received the two-step PTCSL treatment.</li>
		<li>Select those patients who were confirmed to have hepatic and extrahepatic bile duct stones by adjuvant examination.</li>
		<li>Select patients who had undergone previous complicated abdominal surgery, such as partial gastrectomy combined with biliary-intestinal anastomosis or Billroth II reconstruction, or who had anatomical abnormalities and were unable to undergo an endoscopic retrograde cholangiao pancreatography (ERCP) examination.</li>
		<li>Select patients with liver function preoperatively assessed as Child-Pugh A or B grades.</li>
		<li>Select patients with normal function of the heart, lung, and other organs.</li>
	</ol>
	</li>
	<li>Ensure the availability of the laparoscopic imaging system, images of the pneumoperitoneum, Wolf nephroscope, adjustable pressure pump, and hydroelectric lithotripter.</li>
</ol>
2. Procedure
<ol>
	<li>Percutaneous transhepatic cholangial drainage (PTCD)
	<ol>
		<li>Insert an indwelling 8F biliary drainage tube 1 week before the operation to drain and reduce the swelling of bile duct.</li>
		<li>Wait for the sinus tract to become stable at 1 week after PTCD. 
		&#8203;NOTE: The puncture methodology must be chosen according to the particular area of bile conduit calculi when operating. For example, the left hepatic duct approach is performed under the xiphoid process and abdominal wall of the lower edge of the right costal arch.</li>
	</ol>
	</li>
</ol>
3. Percutaneous transhepatic choledochoscopic lithotomy (PTCSL)
<ol>
	<li>Before administering general anesthesia, instruct the patient to lie flat on the operating table. Following general anesthesia, disinfect the surgical site 3x with iodophor.</li>
	<li>Inject 20 mL of saline into the bile duct along the drainage tube; pull the PTCD tube out after a guide wire is inserted into it.</li>
	<li>For placement of the fascia dilator and sheath, expand the sinus using a 16F expander and join a 16F belt dilator so that the 16F sheath can reach the bile duct where the stone might have been placed.</li>
	<li>After locating the stones, use clamping forceps to both break and remove the stones. For hard stones, use a hydraulic lithotripter to break the stone. Wash out small stones and powdered stones using an adjustable pressure pump. At the end of the procedure, leave a drainage tube inside the patient for 1 week (Figure 1).</li>
</ol>

<ol><li>Shu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Robotic-assisted+laparoscopic+surgery+for+complex+hepatolithiasis%3A+a+propensity+score+matching+analysis%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Robotic-assisted laparoscopic surgery for complex hepatolithiasis: a propensity score matching analysis.</a> Surgical Endoscopy. 33 (8), 2539-2547 (2019).</li>
<li>Korkes, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+treatment+of+complex+biliary+stone+disease+using+endourological+technique+and+literature+review%5BTitle%5D)+AND+%22Einstein%22%5BJournal%5D)">Percutaneous treatment of complex biliary stone disease using endourological technique and literature review.</a> Einstein. 13 (4), 611-615 (2015).</li>
<li>Gamal, E. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+video+choledochoscopic+treatment+of+retained+biliary+stones+via+dilated+t-tube+tract%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Percutaneous video choledochoscopic treatment of retained biliary stones via dilated t-tube tract.</a> Surgical Endoscopy. 15 (5), 473-476 (2001).</li>
<li>Khalid, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+endoscopic+biliary+exploration+in+complex+biliary+stone+disease%3A+Case+series+study%5BTitle%5D)+AND+%22International+Journal+of+Surgery%22%5BJournal%5D)">Percutaneous endoscopic biliary exploration in complex biliary stone disease: Case series study.</a> International Journal of Surgery. 24, 73-78 (2020).</li>
<li>Kim, J. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+transhepatic+cholangioscopic+treatment+of+patients+with+benign+bilio-enteric+anastomotic+strictures%5BTitle%5D)+AND+%22Gastrointestinal+Endoscopy%22%5BJournal%5D)">Percutaneous transhepatic cholangioscopic treatment of patients with benign bilio-enteric anastomotic strictures.</a> Gastrointestinal Endoscopy. 58 (5), 733-738 (2003).</li>
<li>Hwang, J. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Risk+factors+for+recurrent+cholangitis+after+initial+hepatolithiasis+treatment%5BTitle%5D)+AND+%22Journal+of+Clinical+Gastroenterology%22%5BJournal%5D)">Risk factors for recurrent cholangitis after initial hepatolithiasis treatment.</a> Journal of Clinical Gastroenterology. 38 (4), 364-367 (2004).</li>
<li>Bonnel, D. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Common+bile+duct+and+intrahepatic+stones%3A+results+of+transhepatic+electrohydraulic+lithotripsy+in+50+patients%5BTitle%5D)+AND+%22Radiology%22%5BJournal%5D)">Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients.</a> Radiology. 180 (2), 345-348 (1991).</li>
<li>Kondo, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+clinicopathologic+study+of+primary+cholesterol+hepatolithiasis%5BTitle%5D)+AND+%22Hepato-gastroenterology%22%5BJournal%5D)">A clinicopathologic study of primary cholesterol hepatolithiasis.</a> Hepato-gastroenterology. 42 (5), 478-486 (1995).</li>
<li>Williams, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Updated+guideline+on+the+management+of+common+bile+duct+stones+%28CBDS%29%5BTitle%5D)+AND+%22Gut%22%5BJournal%5D)">Updated guideline on the management of common bile duct stones (CBDS).</a> Gut. 66 (5), 765-782 (2017).</li>
<li>Makuuchi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Ultrasonically+guided+cholangiography+and+bile+drainage%5BTitle%5D)+AND+%22Ultrasound+in+Medicine+%26+Biology%22%5BJournal%5D)">Ultrasonically guided cholangiography and bile drainage.</a> Ultrasound in Medicine & Biology. 10 (5), 617-623 (1984).</li>
<li>Jeng, K. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+transhepatic+cholangioscopy+in+the+treatment+of+complicated+intrahepatic+biliary+strictures+and+hepatolithiasis+with+internal+metallic+stent%5BTitle%5D)+AND+%22Surgical+Laparoscopy%22%5BJournal%5D)">Percutaneous transhepatic cholangioscopy in the treatment of complicated intrahepatic biliary strictures and hepatolithiasis with internal metallic stent.</a> Surgical Laparoscopy. 10 (5), 278-283 (2000).</li>
<li>Zhuo, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+transhepatic+choledochoscopic+lithotomy+%28PTCSL%29+is+effective+for+the+treatment+of+intrahepatic+and+extrahepatic+choledocholithiasis%5BTitle%5D)+AND+%22Surgical+Laparoscopy%2C+Endoscopy+%26+Percutaneous+Techniques%22%5BJournal%5D)">Percutaneous transhepatic choledochoscopic lithotomy (PTCSL) is effective for the treatment of intrahepatic and extrahepatic choledocholithiasis.</a> Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 31 (3), 326-330 (2020).</li>
<li>Hazey, J. W., McCreary, M., Guy, G., Melvin, W. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Efficacy+of+percutaneous+treatment+of+biliary+tract+calculi+using+the+holmium%3A+YAG+laser%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Efficacy of percutaneous treatment of biliary tract calculi using the holmium: YAG laser.</a> Surgical Endoscopy. 21 (7), 1180-1183 (2007).</li>
<li>Ozturk, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((New+surgical+technique+applied+with+urological+instruments+in+bilobar+multiple+hepatolithiasis%3A+Ultra-mini+percutaneous+hepatolithotomy%5BTitle%5D)+AND+%22Turkish+Journal+of+Urology%22%5BJournal%5D)">New surgical technique applied with urological instruments in bilobar multiple hepatolithiasis: Ultra-mini percutaneous hepatolithotomy.</a> Turkish Journal of Urology. 43 (3), 371-377 (2017).</li>
<li>Ozcan, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+transhepatic+removal+of+bile+duct+stones%3A+results+of+261+patients%5BTitle%5D)+AND+%22Cardiovascular+and+Interventional+Radiology%22%5BJournal%5D)">Percutaneous transhepatic removal of bile duct stones: results of 261 patients.</a> Cardiovascular and Interventional Radiology. 35 (3), 621-627 (2012).</li>
<li>Kint, J. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+treatment+of+common+bile+duct+stones%3A+results+and+complications+in+110+consecutive+patients%5BTitle%5D)+AND+%22Digestive+Surgery%22%5BJournal%5D)">Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients.</a> Digestive Surgery. 32 (1), 9-15 (2015).</li>
<li>Yeh, Y. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+trans-hepatic+cholangioscopy+and+lithotripsy+in+the+treatment+of+intrahepatic+stones%3A+a+study+with+5+year+follow-up%5BTitle%5D)+AND+%22Gastrointestinal+Endoscopy%22%5BJournal%5D)">Percutaneous trans-hepatic cholangioscopy and lithotripsy in the treatment of intrahepatic stones: a study with 5 year follow-up.</a> Gastrointestinal Endoscopy. 42 (1), 13-18 (1995).</li>
<li>Jan, Y. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+trans-hepatic+cholangioscopic+lithotomy+for+hepatolithiasis%3A+long-term+results%5BTitle%5D)+AND+%22Chang+Gung+Medical+Journal%22%5BJournal%5D)">Percutaneous trans-hepatic cholangioscopic lithotomy for hepatolithiasis: long-term results.</a> Chang Gung Medical Journal. 17 (1), 149(1994).</li>
<li>Cheon, Y. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Evaluation+of+long-term+results+and+recurrent+factors+after+operative+and+nonoperative+treatment+for+hepatolithiasis%5BTitle%5D)+AND+%22Surgery%22%5BJournal%5D)">Evaluation of long-term results and recurrent factors after operative and nonoperative treatment for hepatolithiasis.</a> Surgery. 146 (5), 843-853 (2009).</li>
<li>Tsutsumi, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+comparative+evaluation+of+treatment+methods+for+bile+duct+stones+after+hepaticojejunostomy+between+percutaneous+transhepatic+cholangioscopy+and+peroral%2C+short+double-balloon+enteroscopy%5BTitle%5D)+AND+%22Therapeutic+Advances+in+Gastroenterology%22%5BJournal%5D)">A comparative evaluation of treatment methods for bile duct stones after hepaticojejunostomy between percutaneous transhepatic cholangioscopy and peroral, short double-balloon enteroscopy.</a> Therapeutic Advances in Gastroenterology. 10 (1), 54-67 (2017).</li>
</ol>

The authors have no conflicts of interest to disclose.

Intrahepatic and extrahepatic choledocholithiasis contribute to biliary obstruction, and the associated cholangitis could lead to gram-negative endotoxemia with clinical manifestations of septic shock or multiorgan dysfunction. Thus, biliary stones represent a complex disease that can be challenging for surgeons, especially in cases of patients who have had previous complex abdominal surgeries or patients with abnormal anatomical structure. PTCSL is being widely used around the world, but there remains a need for innovat...

Intrahepatic and extrahepatic choledocholithiasis is a complex medical problem faced by surgeons and is very common in East Asian countries1. At present, surgical intervention is required for most choledocholithiasis, while the main treatments for bile duct stones include open surgery, percutaneous transhepatic choledochoscopic lithotomy (PTCSL), laparoscopic lithotomy2, percutaneous endoscopic biliary exploration3,4, and endoscopic retrograde cholangiopancreatography. However, patients with bilioenteric anastomosis or Billroth II reconstruction, with an abnormal anatomical structure such as a duodenal periampullary diverticulum, which makes the biliary duct difficult to access through an endoscopic approach5,6,7,8, or who have had previous complex abdominal surgeries, including partial gastrectomy, could not undergo endoscopic therapy or laparoscopic lithotomy. Endoscopic therapy may also not be suitable for hepatolithiasis with large and impacted stones. Therefore, PTCSL, in general, may be a better choice9.
The traditional PTCS approach follows such a procedure to expand the sinus gradually and perform percutaneous transhepatic biliary drainage10,11, which requires a relatively long hospitalization cycle, usually between 2 and 3 weeks, leading to the potential for biliary fistula, biliary tract infection, bleeding, and peritonitis, with multiple expanding sheath sizes. The procedure is composed of two parts. In the first step, the target bile duct is punctured, and the guide wire is inserted while observing the bile outflow. Then, a dilator is used to slowly expand the channel along the guide wire. After the channel is successfully established, the dilator is pulled out, a drain is placed into the target bile duct, and the guide wire is pulled out.
The percutaneous liver puncture and drainage (PTCD) is complete if the bile drainage is unobstructed and the drain is fixed without blood outflow. The sinus tract becomes stable 1 week after PTCD, when it can then be expanded. The guide wire is placed into the drain tube and expanded through the sinus tract along the guide wire with a 10F dilator, and finally placed into a 10F drain. The sinus tract is expanded once a week after surgery, with a 2F size increase each time, so that the sinus tract can be expanded to 16F at 4 weeks after PTCD. In the second step, after expansion of the sinus tract to 16F, the surgery to remove the stone is performed using a biliary fiber lens. Therefore, the traditional PTCSL described above requires a treatment cycle and contributes to high economic pressure for the patients. Moreover, low stone extraction efficiency and repeated and multiple surgical procedures for stone removal are also inevitable disadvantages of traditional PTCS, which limits the use of this technology.
From January 2013, we began to apply PTCS for the minimally invasive treatment of patients with complex intrahepatic and extrahepatic choledocholithiasis in our hospital but modified some key steps of traditional PTCS. In the first step, the surgery was performed at 1 week after PTCD, just when the sinus tract became stable, and the sinus was expanded to 16F directly, using a 16F expander which greatly reduced the preoperative preparation time. In the second step, different from the traditional technology, a Wolf nephroscope was used instead of a traditional choledochoscope to perform the operation, which we refer to as the &#34;two-step PTCSL method.&#34; To determine whether the PTCSL procedure was safe, minimally invasive, and efficient, this study retrospectively reviewed 81 patients with intrahepatic and extrahepatic choledocholithiasis treated by the two-step PTCSL method from January 2013 to January 2020.

<table><tbody><tr><td>0.9% Normal saline solution</td><td></td><td>-</td><td></td></tr><tr><td>16-F series fascia dilator</td><td></td><td>type PLVW, Cook Medical</td><td></td></tr><tr><td>adjustable pressure pump</td><td></td><td>type APL; Guangzhou Jielun Medical Equipment Co. , Ltd, Guangdong Province, China</td><td></td></tr><tr><td>biliary balloon dilator</td><td></td><td>ATB advance; Cook Medical</td><td></td></tr><tr><td>blade</td><td></td><td>-</td><td></td></tr><tr><td>camera system</td><td></td><td>1088i HD Camera Control Unit, PAL 220 V; Stryker Corporation</td><td></td></tr><tr><td>Cavity mirror protective sleeve</td><td></td><td>-</td><td></td></tr><tr><td>clamp</td><td></td><td>5Fr, Richard Wolf GmbH, Germany</td><td></td></tr><tr><td>color ultrasound machine</td><td></td><td>DC-N2S, Mindray</td><td></td></tr><tr><td>Cook net basket</td><td></td><td>NGE-017115-MB, COOK Medical Inc. , Bloomington, USA</td><td></td></tr><tr><td>drainage pack</td><td></td><td>-</td><td></td></tr><tr><td>expander</td><td></td><td>-</td><td></td></tr><tr><td>guide wire</td><td></td><td>-</td><td></td></tr><tr><td>hydroelectric lithotripter</td><td></td><td>Aymed Medical, &lt;img alt=&quot;Equation 1&quot; src=&quot;/files/ftp_upload/63206/63206eq01.jpg&quot; style=&quot;margin: auto;&quot;/&gt;stanbul, Turkey</td><td></td></tr><tr><td>&amp;nbsp;Iodophor</td><td></td><td>-</td><td></td></tr><tr><td>&amp;nbsp;Kidney basin</td><td></td><td>-</td><td></td></tr><tr><td>light source</td><td></td><td>Voice-control compatible X8000 Xenon Light Source of 300 W;Stryker Corporation, MI</td><td></td></tr><tr><td>Medical syringe</td><td></td><td>-</td><td></td></tr><tr><td>puncture needle</td><td></td><td>-</td><td></td></tr><tr><td>suction apparatus</td><td></td><td>-</td><td></td></tr><tr><td>surgical gauze</td><td></td><td>-</td><td></td></tr><tr><td>trocar</td><td></td><td>-</td><td></td></tr><tr><td>Wolf nephroscope</td><td></td><td>12-degree Ultra-Wide-Angle Ureteroreno-scope; Richard Wolf GmbH, Germany</td><td></td></tr><tr><td>zebra guide wire</td><td></td><td>type HAW; Cook Medical, Bloomington, IN</td><td></td></tr></tbody></table>

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.

All patients had their biliary tract stones cleared successfully, with 58 patients (58/81, 72%) having bile duct stones completely removed after the first operation, 18 patients (18/81, 22%) requiring a second operation, and five patients (5/81, 6%) undergoing a third operation to completely remove the stones. Three patients had recurrent intrahepatic cholelithiasis in the 5th and 6th postoperative years. There were 56 patients (56/81, 68.7%) who underwent percutaneous liver surgery, as well as 25 p...

Watch this Scientific Journal Video about A Two-Step Method for Percutaneous Transhepatic Choledochoscopic Lithotomy at JoVE.com

A Two-Step Method for Percutaneous Transhepatic Choledochoscopic Lithotomy

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 ...

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2.3K Views.  Shantou University Medical College. This "two-step method" significantly improved the success rate of percutaneous transhepatic choledochoscopy and achieved a better prognosis of intrahepatic and extrahepatic choledocholithiasis.

Video: A Two-Step Method for Percutaneous Transhepatic Choledochoscopic Lithotomy

Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy

Laparoscopic hepatectomy has been reported in many studies, and it is the mainstream method of liver resection. In some particular cases, such as when there are tumors adjacent to the cystic bed, surgeons cannot palpate the surgical margins through the laparoscopic approach, which leads to uncertainty about R0 resection. Conventionally, the gallbladder is resected first, and the hepatic lobes or segments are resected second. However, tumor tissues can be disseminated in the above cases. To address this issue, based on the recognition of the porta hepatis and intrahepatic anatomy, we propose a unique approach to hepatectomy combined with gallbladder resection by en bloc anatomic resection in situ. Firstly, after dissecting the cystic duct, without cutting the gallbladder primarily, the porta hepatis is pre-occluded by the single lumen ureter; secondly, the left hepatic pedicle is made free by the gap of the Laennec membrane and Hilar plate; thirdly, the assistant is asked to drag the fundus of the gallbladder, and the liver parenchyma tissue is resected using a harmonic scalpel along the ischemia line on the liver surface and intraoperative ultrasound. The whole middle hepatic vein (MHV) and its tributaries appear completely; lastly, the left hepatic vein (LHV) is disconnected, and the specimen is taken out from the abdominal cavity. The tumor, gallbladder, and other surrounding tissues are resected en bloc, which meets the tumor-free criterion, and a wide incisal margin and R0 resection are achieved. Therefore, the laparoscopic hepatectomy with the combination of the en bloc concept and anatomic resection is a safe, effective, and radical method with low postoperative recurrence and metastasis.

Numerous studies have demonstrated the advantages of anatomic resection. Nonetheless, whether anatomic resection can increase R0 resection rates remains controversial. Consequently, the present study describes an innovative procedure involving the en bloc concept combined with anatomic resection in laparoscopic hepatectomy, which can reduce postoperative recurrence and metastasis.

Laparoscopic hepatectomy has been reported in many studies, and it is the mainstream method of liver resection. In some particular cases, such as when ...

Cancer Research

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 ...

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. ...

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 ...

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 ...

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, ...

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), ...