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

Summary

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.

Abstract

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.

Introduction

Cholecystolithiasis is a common clinical disease, with approximately 10-20% of patients developing secondary choledocholithiasis^1,2. Gallstones combined with common bile duct stones are a frequent clinical condition. Bile duct obstruction may lead to abdominal pain, jaundice, biliary tract infections, and even severe shock. The optimal treatment involves relieving the obstruction and removing the lesions.

The current therapeutic approaches for gallbladder stones with common bile duct stones include open cholecystectomy + open common bile duct exploration (OC+OCBDE), endoscopic retro....

Protocol

This protocol follows the ethical guidelines for human research at Dongguan Tungwah Hospital. The patient has signed the relevant informed consent form.

NOTE: A 78-year-old male patient was admitted with a 3-day history of abdominal pain. CT examination revealed cholecystolithiasis combined with choledocholithiasis, with a common bile duct (CBD) diameter of approximately 10 mm (see Figure 1). The preoperative evaluation showed no surgical contraindications. The instruments and equipment used are detailed in the Table of Materials.

1. Preoperative examination

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Results

The procedure lasted 110 min with an intraoperative blood loss of 10 mL. The drainage tube was removed on postoperative day 4 (POD4), and the patient was discharged uneventfully on POD5. Intraoperative laparoscopic ultrasound (LUS) was employed to clearly delineate the cystic duct, common bile duct, and vascular anatomy and the size, quantity, and precise location of common bile duct stones (see Figure 4), enabling real-time intraoperative guidance. No perioperative complications-including b.......

Discussion

LC+LCBDE and ERCP+LC are the primary minimally invasive approaches for gallbladder stones with common bile duct stones. Compared to ERCP, LCBDE offers advantages in managing larger stones, preserving papillary function, and avoiding staged procedures^15,16.

The role of T-tube drainage post-LCBDE remains debated. While justified in cases of biliary hypertension, residual stones, strictures, or acute cholangitis, primary closure is recomm.......

Materials

Name	Company	Catalog Number	Comments
Basket catheter	Guangzhou Manya Medical Technology Co., Ltd	WL-F65-115M
Cholangioscope	Olympus	CHF-V
Disposable laparoscopic trocar	Mindray	CW-Z346
Electrocautery hook	Visionstar	HV300B
Laparoscopic system	KARL STORZ	26003AA
Laparoscopic ultrasound	BK Medical	8666-RF
Polydioxanone suture	ETHICON	Z303H
Ultrasonic dissector	ETHICON	ACE+7