Name: laparoscopic common bile duct exploration in patients with a previous history of biliary tract surgery
Uploaded: 2023-02-10T13:43:00
Description: Watch this Scientific Journal Video about Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery at JoVE.com

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 ...

<ol>
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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 border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<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 ...

This protocol aims to develop a programmed procedure by investigating the surgical approaches and anatomical landmarks of laparoscopic common bile duct exploration, or 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 time, reduce complications, improve surgical safety, and further promote the application of this technique. In the 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 helium to expose the common bile duct or CBD.In the anterior hepatoduodenal ligament approach, separate the duodenum from the hepatic hilum downward to expose the CBD anterior to the hepatoduodenal ligament. In the right hepatoduodenal ligament approach, separate the hepatic flexure of the colon adhered to the hepatic hilum, starting from the right lateral side of the hepatoduodenal ligament downward to expose the area between the right sub hepatic space and the omental foramen, thereby determining the position of the CBD. In the hybrid approach, combine two or three of the demonstrated approaches, which mainly depend on the location of adhesion.If there is adhesion in the middle of the anterior abdominal wall, use the hepatic round ligament approach. If adhesion exists in the front and on both sides of the CBD, use the anterior hepatoduodenal ligament approach. If there is adhesion in the right upper abdomen, use the right hepatoduodenal ligament approach.Use the hybrid approach if there is extensive adhesion in the abdominal cavity. Use all 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. Identify the parietal peritoneum and gastrointestinal cirrhosa.Use noninvasive grasping forceps to clamp and pull the gastrointestinal tract, adhering to the abdominal wall with the appropriate traction tension. Then, separate and release the adhesions close to the parietal peritoneum and away from the gastrointestinal cirrhosa. Separate the loose adhesions with a blunt dissection or ultrasonic scalpel.Then, release the dense adhesions or adhesions involving intestines with scissors to avoid thermal damage. Next, identify the hepatic round ligament landmark. 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. 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 duodenum. If the injury is unavoidable, separate the adhesions close to the liver under the principle of injuring the liver rather than the gastrointestinal tract.The gastric antrum and the first and second segments of the duodenum tend to move up and seal the first hepatic hilar region through the 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 expose the CBD further.To expose the CBD by identifying the 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.To perform 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. Remove the stones directly using forceps. To perform laparoscopic lithotomy via blind basket extraction, insert the stone basket into the CBD and open it.Then, repeatedly pull the basket up and down without colodicoscopic assistance. Remove the stones that cannot be squeezed toward the CBD incision via blind basket extraction, which substantially shortens the time of the colodicoscopic lithotomy. To remove the stones by CBD flushing with saline, insert a silicone tube into the CBD.Use a 50 milliliter syringe to inject saline into the CBD through the silicone tube and flush out the small stones. To perform colodicoscopic lithotomy, insert the colodicoscope into the CBD and continuously inject saline through the colodicoscope flushing channel. Put the stone extraction basket into the CBD through the instrument channel of the colodicoscope.Open the basket and then take out the stones under the direct vision of the colodicoscope. A total of 174 patients successfully underwent CBD exploration and three patients were converted to laparotomy due to intraoperative hemorrhage of the CBD wall. The mean operation time was approximately 163.72 minutes.The mean intraoperative blood loss was approximately 87.51 milliliters. and the time to the first flatus was 28.94 hours. The mean postoperative drainage volume was approximately 196.27 milliliters.And the length of hospital stay was 6.93 days. The postoperative complication rate was 9.0%There were three cases of postoperative bile leakage, one case of postoperative bleeding, five cases of residual stones, one case of abdominal infection, and six cases of incision infection. For successful surgical outcomes, it is crucial to take utmost care while performing adhesion separation and CBD exposure based on anatomical landmarks.

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