ai_agent

We thank the anaesthesiologists and operating room nurses who assisted with the operation.

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
<ol>
	<li>Blood tests: Perform liver function tests and kidney function tests, as well as complete blood count, coagulation profile, blood type, and crossmatch.</li>
	<li>Diagnostic imaging and evaluations: Perform electrocardiogram, chest X-ray, cardiovascular assessment, color Doppler ultrasound of the liver and biliary system, and computed tomography (CT) scan of the upper abdomen.</li>
</ol>
2. Operative procedure
<ol>
	<li>Perform endotracheal intubation and position the patient supine. Execute routine disinfection using a povidone-iodine solution. 
	NOTE: General anesthesia was administered according to institutionally approved protocols.</li>
	<li>Perform a standard four-port technique of laparoscopic cholecystectomy (see Figure 2).
	<ol>
		<li>Create a 10-mm vertical incision subumbilically, and introduce CO&#8322; gas using a Veress needle to establish pneumoperitoneum at 12 mmHg.</li>
		<li>Then, place the 10-mm trocar and laparoscope infraumbilically. Under the direct visualization provided by the laparoscope, place a subxiphoid port (10 mm), right midclavicular port (5 mm), and right anterior axillary port (5 mm).</li>
	</ol>
	</li>
	<li>Surgical steps (see Figure 3 and Figure 4) 
	NOTE: The surgical procedure is performed by a surgeon with the assistance of an assistant.
	<ol>
		<li>Perform laparoscopic exploration of the abdominal cavity by following this sequence: top to bottom, solid organs first, then hollow organs, abdominal cavity first, then pelvic cavity, to systematically assess abdominal lesions (see Figure 3A).</li>
		<li>Use LUS to probe the hepatic portal area, place the laparoscopic probe at the porta hepatis region through the subxiphoid port (10 mm), and move the probe up and down. Distinguish bile ducts and blood vessels via blood flow signals and assess stone distribution (see Figure 3B and Figure 4A,B).</li>
		<li>Elevate the gallbladder fundus with atraumatic forceps (Assistant). Retract and expand Calot&#39;s triangle to optimize exposure (Surgeon). Dissect Calot&#39;s triangle layer by layer using an electrohook or ultrasonic scalpel (see Figure 3C).</li>
		<li>Use LUS to confirm the CBD location. Straighten a 5-0 round-bodied needle with a needle holder and tie a No.4 silk suture to its tail to prevent accidental loss.</li>
		<li>Grasp the needle midpoint with laparoscopic forceps connected to electrocautery (20 W). Make a 1-cm longitudinal incision on the anterior CBD wall (see Figure 3D).</li>
		<li>Insert the choledochoscope through the subxiphoid port into the CBD. Visualize and retrieve calculi using a stone retrieval basket (see Figure 3E).</li>
		<li>Inspect proximal and distal bile ducts for residual stones. Confirm duodenal papillary sphincter competence. Close the choledochotomy with a 5-0 polydioxanone suture (PDS) using continuous or interrupted sutures (1-2 mm spacing) (see Figure 3F,G).</li>
		<li>Place a sterile gauze pledget on the CBD to detect bile leakage. Complete the gallbladder resection using ultrasonic shears or electrocautery.</li>
		<li>Extract the gallbladder via the subxiphoid port. Conduct laparoscopic ultrasound (LUS) scanning along the extrahepatic bile duct axis in the hepatic hilum. Confirm the absence of residual calculi and ensure patency of biliary anastomosis without stricture (see Figure 3H).</li>
		<li>Insert a drainage tube into the subhepatic epiploic foramen (foramen of Winslow) through the 5-mm right anterior axillary port (see Figure 3I).</li>
	</ol>
	</li>
</ol>
3. Postoperative care
<ol>
	<li>Continuously monitor heart rate, blood pressure, respiratory rate, and body temperature.</li>
	<li>Administer intravenous fluids to maintain hydration, electrolyte balance, and acid-base equilibrium. Administer IV antibiotics and hepatoprotective agents postoperatively.</li>
	<li>Initiate oral water intake 6 h postoperatively. Encourage early bedside mobilization to promote recovery.</li>
	<li>Maintain patency of drainage tubes. Monitor for bile leakage signs (e.g., yellowish drainage, abdominal distension).</li>
</ol>

<ol><li>Marilee-L, F., Robert-L, B., Andrew-J, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Choledocholithiasis%3A+Evolving+standards+for+diagnosis+and+management%5BTitle%5D)+AND+%22World+J+Gastroenterol%22%5BJournal%5D)">Choledocholithiasis: Evolving standards for diagnosis and management.</a> World J Gastroenterol. 12 (20), 3162-3167 (2006).</li>
<li>Costi, R., Gnocchi, A., Di Mario, F., Sarli, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Diagnosis+and+management+of+choledocholithiasis+in+the+golden+age+of+imaging%2C+endoscopy+and+laparoscopy%5BTitle%5D)+AND+%22World+J.+Gastroenterol%22%5BJournal%5D)">Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy.</a> World J. Gastroenterol. 20 (37), 13382-13401 (2014).</li>
<li>Shojaiefard, A., Esmaeilzadeh, M., Ghafouri, A., Mehrabi, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Various+techniques+for+the+surgical+treatment+of+common+bile+duct+stones%3A+a+meta+review%5BTitle%5D)+AND+%22Gastroenterol+Res+Pract%22%5BJournal%5D)">Various techniques for the surgical treatment of common bile duct stones: a meta review.</a> Gastroenterol Res Pract. 2009, 840208(2009).</li>
<li>Naotaka, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Evidence-based+clinical+practice+guidelines+for+cholelithiasis%5BTitle%5D)+AND+%22J+Gastroenterol%22%5BJournal%5D)">Evidence-based clinical practice guidelines for cholelithiasis.</a> J Gastroenterol. 58 (9), 801-833 (2023).</li>
<li>Chen, C. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+fading+role+of+T-tube+in+laparoscopic+choledochotomy%3A+primary+choledochorrhaphy+and+over+pigtail+j+and+endonasobiliary+drainage+tubes%5BTitle%5D)+AND+%22J+Laparoendosc+Adv+Surg+Tech+A%22%5BJournal%5D)">The fading role of T-tube in laparoscopic choledochotomy: primary choledochorrhaphy and over pigtail j and endonasobiliary drainage tubes.</a> J Laparoendosc Adv Surg Tech A. 20 (10), 807-811 (2000).</li>
<li>Zhang, H. W., Chen, Y. J., Wu, C. H., Li, W. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+common+bile+duct+exploration+with+primary+closure+for+management+of+choledocholithiasis%3A+A+retrospective+analysis+and+comparison+with+conventional+T-tube+drainage%5BTitle%5D)+AND+%22Am+Surg%22%5BJournal%5D)">Laparoscopic common bile duct exploration with primary closure for management of choledocholithiasis: A retrospective analysis and comparison with conventional T-tube drainage.</a> Am Surg. 80 (2), 178-181 (2014).</li>
<li>Podda, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Systematic+review+with+meta-analysis+of+studies+comparing+primary+duct+closure+and+T-tube+drainage+after+laparoscopic+common+bile+duct+exploration+for+choledocholithiasis%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Systematic review with meta-analysis of studies comparing primary duct closure and T-tube drainage after laparoscopic common bile duct exploration for choledocholithiasis.</a> Surg Endosc. 30 (3), 845-861 (2016).</li>
<li>Kurinchi, S. G., Rahul, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((T-tube+drainage+versus+primary+closure+after+laparoscopic+common+bile+duct+exploration%5BTitle%5D)+AND+%22Cochrane+Database+Syst+Rev%22%5BJournal%5D)">T-tube drainage versus primary closure after laparoscopic common bile duct exploration.</a> Cochrane Database Syst Rev. 21 (6), CD005641(2013).</li>
<li>Yan, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+safety+and+efficacy+of+primary+duct+closure+without+endoscopic+nasobiliary+drainage+after+laparoscopic+common+bile+duct+exploration%5BTitle%5D)+AND+%22Gastrointest+Tumors%22%5BJournal%5D)">The safety and efficacy of primary duct closure without endoscopic nasobiliary drainage after laparoscopic common bile duct exploration.</a> Gastrointest Tumors. 7 (4), 117-124 (2020).</li>
<li>Brent, T. X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Biliary+anatomy+and+variations%5BTitle%5D)+AND+%22Surg+Clin+North+A%22%5BJournal%5D)">Biliary anatomy and variations.</a> Surg Clin North A. 104 (6), 1137-1144 (2024).</li>
<li>Onofrio, A. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Vascular+and+biliary+variants+in+the+liver%3A+implications+for+liver+surgery%5BTitle%5D)+AND+%22Radiographics%22%5BJournal%5D)">Vascular and biliary variants in the liver: implications for liver surgery.</a> Radiographics. 28 (2), 359-378 (2008).</li>
<li>Wu, J. S., Peng, C., Mao, X. -H., Lv, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Bile+duct+injuries+associated+with+laparoscopic+and+open+cholecystectomy%3A+sixteen-year+experience%5BTitle%5D)+AND+%22World+J+Gastroenterol%22%5BJournal%5D)">Bile duct injuries associated with laparoscopic and open cholecystectomy: sixteen-year experience.</a> World J Gastroenterol. 13 (16), 2374-2378 (2007).</li>
<li>Jamal, K. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Meta-analysis+of+the+diagnostic+accuracy+of+laparoscopic+ultrasonography+and+intraoperative+cholangiography+in+detection+of+common+bile+duct+stones%5BTitle%5D)+AND+%22Ann+R+Coll+Surg+Engl%22%5BJournal%5D)">Meta-analysis of the diagnostic accuracy of laparoscopic ultrasonography and intraoperative cholangiography in detection of common bile duct stones.</a> Ann R Coll Surg Engl. 98 (4), 244-249 (2016).</li>
<li>Omer, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+ultrasonography+versus+intra-operative+cholangiogram+for+the+detection+of+common+bile+duct+stones+during+laparoscopic+cholecystectomy%3A+a+meta-analysis+of+diagnostic+accuracy%5BTitle%5D)+AND+%22Int+J+Surg%22%5BJournal%5D)">Laparoscopic ultrasonography versus intra-operative cholangiogram for the detection of common bile duct stones during laparoscopic cholecystectomy: a meta-analysis of diagnostic accuracy.</a> Int J Surg. 12 (7), 712-719 (2014).</li>
<li>Rogers, S. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prospective+randomized+trial+of+LC%2BLCBDE+vs+ERCP%2FS%2BLC+for+common+bile+duct+stone+disease%5BTitle%5D)+AND+%22Arch+Surg%22%5BJournal%5D)">Prospective randomized trial of LC+LCBDE vs ERCP/S+LC for common bile duct stone disease.</a> Arch Surg. 145 (1), 28-33 (2010).</li>
<li>Salminen, P., Laine, S., Gullichsen, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Severe+and+fatal+complications+after+ERCP%3A+Analysis+of+2555+procedures+in+a+single+experienced+center%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Severe and fatal complications after ERCP: Analysis of 2555 procedures in a single experienced center.</a> Surg Endosc. 22 (9), 1965-1970 (2008).</li>
<li>Jiang, C., Zhao, X. H., Cheng, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((T-tube+use+after+laparoscopic+common+bile+duct+exploration%5BTitle%5D)+AND+%22JSLS%22%5BJournal%5D)">T-tube use after laparoscopic common bile duct exploration.</a> JSLS. 23 (1), e2018.00077(2019).</li>
<li>Xie, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Is+T-tube+drainage+no+longer+needed+for+laparoscopic+common+bile+duct+exploration%3F+A+retrospective+analysis+and+literature+review%5BTitle%5D)+AND+%22Videosurgery%22%5BJournal%5D)">Is T-tube drainage no longer needed for laparoscopic common bile duct exploration? A retrospective analysis and literature review.</a> Videosurgery. 18 (1), 99-107 (2023).</li>
<li>Atstupens, K., Mukans, M., Plaudis, H., Pupelis, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+role+of+laparoscopic+ultrasonography+in+the+evaluation+of+suspected+choledocholithiasis.+A+single-center+experience%5BTitle%5D)+AND+%22Medicina%22%5BJournal%5D)">The role of laparoscopic ultrasonography in the evaluation of suspected choledocholithiasis. A single-center experience.</a> Medicina. 56 (5), 246-260 (2020).</li>
<li>Maple, J. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+role+of+endoscopy+in+the+evaluation+of+suspected+choledocholithiasis%5BTitle%5D)+AND+%22Gastrointest+Endosc%22%5BJournal%5D)">The role of endoscopy in the evaluation of suspected choledocholithiasis.</a> Gastrointest Endosc. 71 (1), 1-9 (2010).</li>
<li>Estellés, V. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Eleven+years+of+primary+closure+of+common+bile+duct+after+choledochotomy+for+choledocholithiasis%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Eleven years of primary closure of common bile duct after choledochotomy for choledocholithiasis.</a> Surg Endosc. 30 (5), 1975-1982 (2016).</li>
<li>Guan, H., Jiang, G., Mao, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Primary+duct+closure+combined+with+transcystic+drainage+versus+T-tube+drainage+after+laparoscopic+choledochotomy%5BTitle%5D)+AND+%22ANZ+J+Surg%22%5BJournal%5D)">Primary duct closure combined with transcystic drainage versus T-tube drainage after laparoscopic choledochotomy.</a> ANZ J Surg. 89 (7-8), 885-888 (2019).</li>
<li>Khaled, Y. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+bile+duct+exploration+via+choledochotomy+followed+by+primary+duct+closure+is+feasible+and+safe+for+the+treatment+of+choledocholithiasis%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis.</a> Surg Endosc. 27 (11), 4164-4170 (2013).</li>
</ol>

The authors report no conflict of interest.

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 procedures15,16.
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...

Cholecystolithiasis is a common clinical disease, with approximately 10-20% of patients developing secondary choledocholithiasis1,2. 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 retrograde cholangiopancreatography + laparoscopic cholecystectomy (ERCP+LC), laparoscopic cholecystectomy + laparoscopic common bile duct exploration (LC+LCBDE)3,4.
Open surgery is associated with significant trauma and prolonged recovery, typically reserved for cases where minimally invasive techniques are not feasible. ERCP+LC and LC+LCBDE are considered minimally invasive alternatives. However, ERCP+LC requires two separate procedures and carries risks of complications such as bleeding, pancreatitis, duodenal perforation, and impaired Oddi sphincter function. In contrast, LC+LCBDE has been demonstrated as a safe and effective surgical method due to its minimal invasiveness, rapid recovery, shorter hospital stay, and favorable cost-effectiveness5,6,7. Additionally, LCBDE is indicated for patients with ERCP failure, acute cholangitis, acute pancreatitis, or a history of gastrointestinal diversion surgery7.
LCBDE encompasses two primary techniques: primary closure and T-tube drainage. Emerging evidence suggests that primary closure offers advantages over T-tube drainage, including shorter operative and hospitalization durations, as well as reduced postoperative and biliary complications8.
Primary closure of LCBDE can be performed with or without internal stenting. Studies indicate that stent-free primary closure is safe reliable, and avoids potential complications such as stent migration or the need for subsequent stent removal procedures9.
The biliary system exhibits significant anatomical variations10,11, with a reported variation rate of 42.3%12. During laparoscopic surgery, the inability to palpate anatomical structures, combined with tissue edema or visually ambiguous landmarks, increases the risk of bile duct and vascular injuries. Laparoscopic ultrasonography (LUS) addresses these challenges by enabling real-time evaluation of the hepatic portal area, providing dynamic visualization of bile ducts, vasculature, and surrounding tissues, compensating for the lack of tactile feedback, and enhancing surgical safety13,14. While transabdominal ultrasound remains a standard imaging modality for gallstone diagnosis, its accuracy is limited by factors such as abdominal wall thickness, visceral fat, and gastrointestinal gas interference. LUS overcomes these limitations by combining the benefits of conventional ultrasound with high-frequency, high-resolution imaging, direct organ proximity, and real-time intraoperative guidance.

<table><tbody><tr><td>Basket catheter</td><td>Guangzhou Manya Medical Technology Co., Ltd</td><td>WL-F65-115M</td><td></td></tr><tr><td>Cholangioscope</td><td>Olympus</td><td>CHF-V</td><td></td></tr><tr><td>Disposable laparoscopic trocar</td><td>Mindray</td><td>CW-Z346</td><td></td></tr><tr><td>Electrocautery hook</td><td>Visionstar</td><td>HV300B</td><td></td></tr><tr><td>Laparoscopic system</td><td>KARL STORZ</td><td>26003AA</td><td></td></tr><tr><td>Laparoscopic ultrasound</td><td>BK Medical</td><td>8666-RF</td><td></td></tr><tr><td>Polydioxanone suture</td><td>ETHICON</td><td>Z303H</td><td></td></tr><tr><td>Ultrasonic dissector</td><td>ETHICON</td><td>&amp;nbsp;ACE+7</td><td></td></tr></tbody></table>

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.

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...

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.

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 + ...

application-laparoscopic-ultrasonography-primary-choledochal-suture

Research

JoVE Journal

Medicine

316 Views.  Dongguan Tungwah Hospital. 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. 

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

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 ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

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

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 ...

Laparoscopic Common Bile Duct Exploration Followed by Primary Suture Using a Modified Bile Duct Incision

Cholecystolithiasis is a common clinical disease, and 10-15% of patients with cholecystolithiasis have common bile duct (CBD) stones. Laparoscopic CBD exploration (LCBDE) followed by primary closure has proven to be safe and cost-effective for treating CBD stones and is typically performed via transcystic and transductal approaches. However, traditional LCBDE with choledochotomy may lead to biliary stricture and leakage, and performing choledochoscopy in transcystic LCBDE may be challenging because of the narrow cystic duct. To reduce the incidence rate of biliary stricture and leakage and increase the success rate of choledochoscopy, we propose a modified technique for bile duct incision. We performed LCBDE via a micro longitudinal incision extended along the cystobiliary junction toward the CBD instead of the traditional anterior wall of the CBD or purely transverse transcystic incision. Our micro incision size on CBD only ranged from 5 to 10 mm according to the size of the CBD stones. Using this micro incision technique, which is less invasive, resulted in easier exploration of the CBD and preservation of the ductal wall integrity. This approach encourages surgeons to use primary closure and may be considered a viable alternative choice for patients with ductal stones in the future.

Cholecystolithiasis with common bile duct stones is a common disease; however, traditional common bile duct exploration has its own limitations. We propose a modified micro incision for laparoscopic common bile duct exploration aimed at reducing complication rates.

Cholecystolithiasis is a common clinical disease, and 10-15% of patients with cholecystolithiasis have common bile duct (CBD) stones. Laparoscopic CBD ...

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 ...

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 ...

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Application of Lucilia sericata Larvae in Debridement of Pressure Wounds in Outpatient Settings

Biological therapy using Lucilia sericata larvae has numerous advocates worldwide, yet it is still fairly unknown and not commonly applied in daily practice because of the limited awareness and insufficient experience of medical and nursing personnel. There are case reports suggesting that maggot therapy can be applied and supported by lay caregivers, provided they are supervised and informed by physicians/nurses. The foregoing observation suggests that the method should be considered for implementation by a wider group of caregivers if accepted and meticulously supervised by trained and experienced medical staff. The concerns related to the therapeutic use of maggots in certain regions seem understandable, but are not supported by scientific facts. It should be noted that many therapeutic agents (including brood) used in medicine are of natural origin, and are associated with low production costs and high possibilities of implementation in the course of therapy. By analyzing the literature and using our own clinical and research experience, we have come to conclusions related to using larvae therapy, as a quick and safe method providing cleaning and revitalization in the process of treating wounds of various etiologies, especially pressure ulcers. In the current study, medical-grade Lucilia sericata maggots were applied to remove necrotic tissue from deep pressure sores. The treatment is mostly accepted by both caregivers and patients. In most cases, it is conducted by trained and experienced medical personnel in home and outpatient settings. Over the course of the conducted analyzes involving the collected specimens, there were no statistically significant relationships (p&gt; 0.05) confirmed between the wound surface successfully cleared by brood and variables, such as time from wound formation, location, surface size, and the depth of damage to the tissue structure. The lack of statistical dependence may result from the small size of the studied group. Based on the current findings, we have formulated the following conclusions: Maggot Debridement Therapy (MDT) is a fast and effective method enabling the preparation of the wound bed. The use of MDT in outpatient settings is safe and acceptable for patients and their caregivers.

Application of Lucilia sericata Larvae in Debridement of Pressure Wounds in Outpatient Settings

Maggots of Lucilia sericata were used in the debridement of deep pressure sores in outpatient settings for the treatment of pressure sores involving the complete skin thickness. The technique presented in the article does not pose risks for the patient.

Biological therapy using Lucilia sericata larvae has numerous advocates worldwide, yet it is still fairly unknown and not commonly applied in daily ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

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

Summary

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Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Application of Lucilia sericata Larvae in Debridement of Pressure Wounds in Outpatient Settings

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