Laparoscopic Bile Duct Exploration Research Articles

Choledochoscopy in the laparoscopic treatment of patients with choledocholithiasis: a single-centre study

Choledochoscopy is a minimally invasive procedure used for laparoscopic bile duct exploration and the removal of bile duct stones. However, there is insufficient information available about its advantages in diagnosing choledocholithiasis and its role in laparoscopic choledocholithoextraction.
 Objective — to compare the diagnostic efficacy of imaging techniques and choledochoscopy in patients with choledocholithiasis and to evaluate the role of choledochoscopy in laparoscopic choledocholithoextraction.
 Materials and methods. The study examined the results of 128 patients with calculous cholecystitis and choledocholithiasis who had laparoscopic choledocholithoextraction in combination with choledochoscopy. We assessed the sensitivity and specificity of ultrasound, CT, and MRI in the diagnosis of choledocholithiasis, as well as the efficacy of one‑stage treatment of calculous cholecystitis and choledocholithiasis using choledochoscopy and laparoscopic choledocholithoextraction.
 Results. Imaging techniques demonstrated limited sensitivity and specificity in determining the diameter and number of common bile duct stones. A total of 89 (69.5%) patients achieved complete bile duct clearance after blind laparoscopic choledocholithoextraction: 86 (81.1%) had choledochotomy, and 3 (13.6%) underwent transcystic common bile duct exploration. The combination of choledochoscopy and laparoscopic choledocholithoextraction ensured the complete removal of bile duct stones in 97.6% of patients.
 Conclusions. The imaging techniques used for determining the number of common bile duct stones in choledocholithiasis had sensitivity and specificity rates of 41.4% and 92.7% for ultrasound, 72.7% and 83.3% for CT, and 86.7% and 60.9% for MRI, respectively. A total of 89 (69.5%) patients achieved complete bile duct clearance after blind laparoscopic choledocholithoextraction: 86 (81.1%) had choledochotomy, and 3 (13.6%)underwent transcystic common bile duct exploration. Choledochoscopy was required for laparoscopic choledocholithoextraction in 18.9% of choledochotomy patients and in 86.4% of those who underwent transcystic common bile duct exploration. Choledochoscopy demonstrated an overall bile duct stone clearance rate of 97.6%.

Large Element de novo Choledocholithiasis: A case report

The case is a female 73 years old, with a history of laparoscopic cholecystectomy ten years ago, and is diagnosed with de novo choledocholithiasis. The medical staff conducted two Endoscopic Retrograde CholangioPancreatographies (ERCP). The results of the first one were unresolved choledocholithiasis, endoscopic sphincterotomy, intra and extrahepatic bile duct dilation, and plastic biliary prosthesis placement. In the second one, the results showed an ampulla of Vater with endoprosthesis in situ, which was removed easily. Besides, it was tried to trap the stone with a basket, without success due to dimensions (>45 mm). A Tannenbaum-type biliary stent was placed to ensure biliary drainage. After, the patient was scheduled for a laparoscopic bile duct exploration, and dissection was performed during the surgical procedure until locating a dilated common bile duct of approximately 3 cm. The stone was removed with laparoscopic forceps. Choledochorrhaphy was performed, and a drain was placed.

Antegrade biliary stenting following surgical management of choledocholithiasis

Background: T-tube drainage of the common bile duct following bile duct exploration has been standard surgical practice for most of the past century. An important drawback of surgical duct exploration and clearance over ERCP is the need for prolonged external biliary drainage via T-tubes and consequently added morbidity. As such interest grew in reassessing the need for T-tube drainage after CBD Exploration. This was especially augmented by increased popularity of laparoscopic CBD exploration at the time of cholecystectomy which could provide a solution to both problems in a single sitting. Methods: This is a prospective observational study. We present a series of 31 cases of open and laparoscopic bile duct exploration where we closed the choledochotomy over an endo-biliary stent which was subsequently removed endoscopically, thus obviating external biliary drainage. Results: In this study 31 patients undergoing CBD exploration at our institution between January 2017 and August 2018 were included after informed consent. These patients underwent primary closure of the CBD over an endobiliary stent without any T-tube. The mean age of the patients was 42 years (36-57 yrs). 19 of the patients were female and 12 were male. The average operating time was 135 min (120-150 min) for open surgery and 160 min (140-170 min) for laparoscopic cases. The average number of days of hospitalization was 5 in laparoscopic cases (4-14 days) and 7 in open surgical cases (6-12 days). The median follow up of patients was up to 18moths years (8 mths-2 yrs). There were no cases of bilioma/intra-abdominal collections requiring drainage. On long term follow up we could not find any clinical/laboratory evidence of development of biliary strictures. Conclusions: Endobiliary stenting after open or laparoscopic bile duct exploration is a safe and attractive option for biliary drainage with many advantages over T-tube and can be achieved with minimal additional skill and operative time.

Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review.

The natural history of incidental common bile duct stones (CBDS) is poorly understood. Current evidence is conflicting, with several studies suggesting the majority may pass spontaneously. Despite this, guidelines recommend routine removal even if asymptomatic. This study aimed to systematically reviewthe outcomes of expectant management for CBDS detected on operative cholangiography during cholecystectomy. MEDLINE, Embase and CINAHL databases were systematically searched. Participants were adult patients with CBDS identified by intraoperative cholangiography. Intervention was regarded as any perioperative effort to remove common bile duct stones, including endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic and open bile duct exploration. This was compared to observation. Outcomes of interest included rates of spontaneous stone passage, success of duct clearance and complications. Risk of bias was assessed using the ROBINS-I tool. Eight studies were included. All studies were non-randomized, heterogeneous and at serious risk of bias. In patients observed after a positive IOC, 20.9% went on to have symptomatic retained stones. In patients directed to ERCP for positive IOC, persistent CBDS were found in 50.6%. Spontaneous passage was not associated with stone size. Meta-analysis is dominated by the results from one large database, which recommends intervention for incidental stones, despite low rates of persistent stones seen at postoperative ERCP. Further evidence is required before a definitive recommendation on observation can be made. There is some evidence that asymptomatic stones may be safely observed. In clinical scenarios where the risks of biliary intervention are considered high, a conservative strategy could be more widely considered.

A proposed difficulty grading system for laparoscopic bile duct exploration: benefits to clinical practice, training and research.

A gap remains between the mounting evidence for single session management of bile duct stones and theadoption of this approach. Laparoscopic bile duct exploration (LBDE) is limitedby the scarcity of training opportunities and adequate equipment andby the perception that the technique requires a high skill-set. The aim of this study was to create a new classification of difficulty based on operative characteristics and to stratify postoperative outcomes of easy vs. difficult LBDE irrespective of the surgeon's experience. A cohort of 1335 LBDEs was classified according to the location, number and size of ductal stones, the retrieval technique, utilisation of choledochoscopy and specific biliary pathologies encountered. A combination of features indicated easy (Grades I and II A & B) or difficult (Grades III A and B, IV and V) transcystic or transcholedochal explorations. 78.3% of patients with acute cholecystitis or pancreatitis, 37% with jaundice and 46% with cholangitis had easy explorations. Difficult explorations were more likely to present as emergencies, withobstructive jaundice, previous sphincterotomy and dilated bile ducts on ultrasound scans. 77.7% of easy explorations were transcystic and 62.3% of difficult explorations transductal. Choledochoscopy was utilised in 23.4% of easy vs. 98% of difficult explorations. The use ofbiliary drains,open conversions, median operative time, biliary-related complications, hospital stay, readmissions, and retained stones increased with the difficulty grade. Grades I and II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V. There were 2 deaths in difficulty Grade V and one in Grade IIB. Difficulty grading of LBDE is useful in predicting outcomes and facilitatingcomparison between studies. It ensures fair structuring and assessment of training and progress of the learning curve. LBDEs were easy in 72% with 77% completed transcystically. This may encourage more units to adopt this approach.

Comparison of Efficacy and Safety of Laparoscopic Holmium laser Lithotripsy and Laparoscopic Bile Duct Exploration for Bile Duct Stones: A Systematic Review and Meta-Analysis.

Laparoscopic holmium laser lithotripsy (LHLL) has been used to treat bile duct stones with unclear outcomes. A meta-analysis was conducted to investigate the LHLL and laparoscopic bile duct exploration (LBDE) efficacy and safety in treating bile duct stones. The correlational studies were searched databases, such as PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, and VIP, to identify eligible studies from inception to July 2022. The dichotomous and continuous outcomes were evaluated using odds ratio (OR), risk difference (RD) and weighted mean difference (WMD) with 95% confidence intervals (CIs). Stata 15.0 and Review Manager 5.3 software helped in data analyses. A total of 23 studies with 1,890 patients, primarily from China, were included. The results indicated that operation time (WMD = - 26.94; 95% CI:(- 34.30, - 19.58); P < 0.00001), estimated blood loss (WMD = - 17.97; 95% CI: (- 22.94, - 13.00); P = 0.002), rate of residual stone (OR = 0.15, 95%CI: (0.10, 0.23); P < 0.00001), length of hospital stay (WMD = - 2.88; 95% CI:(- 3.80, - 1.96); P < 0.00001) and time to bowel function recovery (WMD = - 0.59; 95% CI: (- 0.76, - 0.41); P < 0.00001) had statistically significant differences between the two groups. In postoperative complications, biliary leakage (RD = -0.03; 95% CI: (- 0.05, -0.00); P = 0.02), infection (RD = - 0.06; 95% CI: (- 0.09,- 0.03); P < 0.00001) and Hepatic injury (RD = - 0.06; 95% CI: (- 0.11, - 0.01); P = 0.02) revealed statistically significant differences. However, no significant differences were observed in biliary damage (RD = - 0.03; 95% CI: (- 0.06, 0.00); P = 0.06) and hemobilia (RD = - 0.03; 95% CI: (- 0.06, 0.00); P = 0.08). The current meta-analysis indicated that LHLL could be more effective and safer than LBDC. However, these results should be confirmed with a larger sample size and rigorously designed randomized controlled trials.

Utilization of Laparoscopic Choledochoscopy During Bile Duct Exploration and Evaluation of the Wiper Blade Maneuver for Transcystic Intrahepatic Access.

This study aims to examine the indications, techniques, and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the wiper blade maneuver (WBM) for transcystic intrahepatic choledochoscopy. Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particularly with the increasing role of transcystic exploration. The indications, techniques, and operative and postoperative data on choledochoscopy collected prospectively during transcystic and choledo- chotomy explorations were analyzed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochoscopes. Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during 1320 bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilized more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts, and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. Twenty retained stones (2.1%) were encountered but no choledochoscopy related complications. Choledochoscopy should always be performed during a chol- edochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilized in over 50% of explorations, increasing their rate of success. When attempted, the transcystic WBM achieves intrahepatic access in 70%-80%. It should be part of the training curriculum.

Laparoscopic Bile Duct Exploration in Patients with ERCP Failure; Role of Laser Lithotripsy

Laparoscopic Bile Duct Exploration in Patients with ERCP Failure; Role of Laser Lithotripsy

Laparoscopic Bile Duct Exploration during Pregnancy: A Multi-centre Case Series and Literature Review

Laparoscopic Bile Duct Exploration during Pregnancy: A Multi-centre Case Series and Literature Review

Laparoscopic Commen Bile Duct Exploration for Common Bile Duct Stones after Gastric Surgery

Laparoscopic Commen Bile Duct Exploration for Common Bile Duct Stones after Gastric Surgery

Retrospective Review of Early Laparoscopic Transcholedochal Bile Duct Exploration Experience at a South African Hospital

Retrospective Review of Early Laparoscopic Transcholedochal Bile Duct Exploration Experience at a South African Hospital

Safety and Efficacy of Laparoscopic Bile Duct Exploration in Octogenary Patients

Safety and Efficacy of Laparoscopic Bile Duct Exploration in Octogenary Patients

Variations in the Trans-choledochal Laparoscopic Bile Duct Exploration: Is this Time for Consensus Guidelines? Results from a Retrospective Multi-centre Study (R-ALICE)

Variations in the Trans-choledochal Laparoscopic Bile Duct Exploration: Is this Time for Consensus Guidelines? Results from a Retrospective Multi-centre Study (R-ALICE)

A O02 Few patients with bile duct stones are managed with a one-stage approach: Results from a prospective multicentre cohort study

Abstract Background Bile duct stones (BDS) are present in 10–20% of patients with symptomatic gallstones. They require treatment to reduce the risk of further morbidity. There are two accepted treatment methods. A two-stage approach is most common where preoperative magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are followed by laparoscopic cholecystectomy (LC). Less commonly, upfront LC is performed with laparoscopic bile duct exploration (LBDE). Recent evidence suggests patients who undergo ERCP+LC have higher stone clearance rates and a lower rate of bile leakage compared to those who undergo LC+LBDE. However, the latter have lower rates of postoperative pancreatitis and reduced length of stay. Overall morbidity and mortality rates are similar. Although the literature supports the single-stage approach, it is not commonly used across the United Kingdom (UK) or Republic of Ireland (RoI). The reasons for this are not clear. The lack of data on LDBE outcomes from large multicentre studies may be a contributing factor. Most published series are from single institutions and the outcomes of these are difficult to generalise to low-volume centres. This study aimed to analyse the CholeS study dataset to examine LBDE hospital volumes, LBDE-to-LC rates and LBDE outcomes. Methods The CholeS study was a multicentre, prospective population-based cohort study which investigated the variations in practice and outcomes of cholecystectomy. Data were collected from 166 UK/RoI hospitals from the months of March and April 2014. The hospitals were divided into high- and low-volume centres based on the number of LBDEs performed. High-volume centres performed at least two LBDEs per month during the study period and low-volume centres performed less than two per month. Most data were analysed and presented descriptively, using tables, graphs, and percentages for distribution. Where possible, we compared clinically relevant groups using the Chi-squared test to detect differences. A p value of less than 0.05 was considered statistically significant. Results In total, 8820 LCs were performed and 2.9% of patients underwent LBDE. Seventy-seven centres (46.1%) performed at least one LBDE. In these units, 5.4% of patients who underwent LC also underwent LBDE. Almost 90% of the hospitals that performed LBDE carried out less than or equal to five. In contrast, 10.6% of patients underwent ERCP and sphincterotomy. Of the 256 LBDEs, 28.5% underwent preoperative ERCP and 43.8% underwent preoperative MRCP. Eighty seven percent of LBDEs were performed by consultants and 13% by trainees. The laparoscopic-to-open conversion rate was 12.5% and the median operation time was 111 minutes (IQR: 75–155). Among the LBDE cases, the overall postoperative morbidity rate was 21.5% and the bile leak rate was 4.7%. 30-day readmission and 30-day mortality rates were 12.1% and 0.4%, respectively. Bile leak, acute pancreatitis, retained stone and overall morbidity rates following LBDE were compared between the low- and high-volume centres. Bile leak (OR 8.62, 95% CI: 2.26–32.84, p=0.0016) and 30-day morbidity (OR 1.90, 95% CI: 1.05–3.44, p=0.035) were significantly higher in the low-volume units. There was no difference in the rate of postoperative pancreatitis (OR 0.85, 95% CI:0.09–8.3, p=0.8887) or retained stone rate (OR 0.76, 95% CI:0.16–3.68, p=0.7376). Conclusions During the study period, just 2.9% of patients underwent LBDE. The majority of hospitals did not perform this procedure at all and very few were “high-volume” units. Our results suggest that the single-stage management of BDS was underutilised despite the recent evidence which suggests it is a safe and reasonable approach. Our results do not provide any insight into why uptake was low and we suspect the reasons for this are multiple. We argue large retrospective/prospective studies are required to investigate this and hope this information will further guide patient management.

OGBN O06 Sharing Experience of SpyGlass™ Discover and ElectroHydraulic Lithotripsy in Treating Large Bile Duct Stone Through the Trans-Cystic Approach During Laparoscopic Cholecystectomy

Abstract Background The one session management of gallstone (GS) disease associated with bile duct stone (BDS) involves laparoscopic cholecystectomy (LC) with bile duct exploration, which remains the gold standard treatment. A two-session management with ERCP followed by laparoscopic cholecystectomy, subjects patients to preventable ERCP related risks including perforation, bleeding, pancreatitis, incomplete clearance and repeat tests, especially if patient is fit and keen for cholecystectomy. Trans-Cystic bile duct exploration (TC-BDE) appears to have less morbidity than Trans-Ductal BDE (TD-BDE). However, large BDS remain the main challenge for the Trans-Cystic (TC) approach, in addition to factors such as, difficult anatomy and proximally located stones. The development in technology and evolving of spyglass DiscoverTM as 3.6mm choledochoscope with Lockable four-way steering and short tip deflection, that could utilize the electrohydraulic lithotripsy (EHL) has made the TC approach to manage large BDS possible. The aim of this abstract is to share our experience in the utilisation of the spyglass discovery TM and SG-EHL in management of large BDS using the TC approach. Methods Data from laparoscopic cholecystectomies performed by a single surgeon in Tayside NHS between 01/07/2020 and 01/06/2022 has been prospectively collected and evaluated. During the study period, 205 laparoscopic cholecystectomies were performed. From the 205 cases, 118 cases were emergency, and 140 cases involved female patients. Spyglass discover TM and SG-EHL were used in four cases, which will be discussed in the results section. Results Cases-1: 39-year-old female with 12mm BDS. Related medical history includes: 1-Right-nephrectomy that was complicated with abdominal abscess 17 years-ago. 2-Failed ERCP that was complicated with necrosis and collection, necessitating an anterior abdominal drain 2 months ago. TC-BDE and clearance was secured with SG-EHL. Abdominal drain for 5-days. Patient discharged home Day 5. Case-2: A 51-year-old male with alcoholic liver cirrhosis and ascending cholangitis due to 17mm BDS and Gallstone. Trial of TC-BDE that was converted to transductal due to friable inflamed cystic-duct and proximal location of BDS at the confluence. Successful SG-EHL helped in minimizing the size of duct opening. Cystic duct biliary drain, and abdominal drain were placed. CD drain was removed after clear tube cholangiography Day 3. Patient developed bile leak that was treated conservatively, and patient discharged after 15-days, abdominal drain was removed after 8-weeks. Case-3: 71-year-old female with 15mm BDS was cleared trans-cystically using SG-EHL. No abdominal drains. Patient had raised inflammatory marker post-surgery treated with antibiotics and patient discharged home Day 4. Case-4: 64-year-old male with12 mm BDS, with previous failed ERCP due to complex duodenal diverticula, TC-BDE and clearance was achieved using SG-EHL LC. Abdominal drain was removed and patient discharge home Day 2. Conclusions This study demonstrates that one session management of large BDS associated with GS, is safe and feasible using trans-cystic approach, with the utilization of the TC approach along with the available technology, the SpyGlass™ Discover and electrohydraulic lithotripsy. Although, the transductal approach might be necessary to ensure bile duct clearance, utilizing SG-EHL might prove beneficial in reducing the size of bile duct opening. Discussion with the patient and informed consent are essential to ensure Patient-specific therapy. A one session management of GS disease should be offered to patients, if indicated, with available support and expertise. More training opportunities in Laparoscopic bile duct exploration is needed to increase the patient's chance of receiving the gold standard treatment for BDS associated with GS.

OGBN P21 A complex case of gallbladder and CBD stones treated with Laparoscopic Cholecystectomy and Trans-Cystic lithotripsy using SpyGlass™ Discover post failed ERCP

Abstract Background Laparoscopic Cholecystectomy and bile duct exploration remain the gold standard treatment for gallstone disease associated with bile duct stones. However, interval two session management with ERCP followed by Laparoscopic Cholecystectomy should be avoided. It exposes patients to preventable risk of perforation, bleeding, and pancreatitis, especially if the patient is fit and keen for surgery. Trans-Cystic bile duct exploration (TC BDE) appears to have less morbidity than Trans- Ductal bile duct exploration (TD BDE). However, large bile duct stones remain the main challenge for Trans-Cystic approach along with distorted anatomy. Methods We present a 48-year-old female with symptomatic gallstone disease and a complex past surgical history. Results Trial of ERCP failed despite Needle-knife papillotomy due to large mobile and hard papilla. Unfortunately, the patient suffered post ECRP pancreatitis that was complicated by an abdominal collection around the head of the pancreas. The collection required radiologic drainage through the anterior abdominal wall, 13 days post-pancreatitis. The patient recovered well and was listed for a Laparoscopic Cholecystectomy and bile duct exploration with high risk of conversion to open, 6 weeks after discharge. The operation was challenging due to presence of adhesions and shrunken gallbladder (Nassar grade IV). Trans-Cystic BDE was performed using basket inside catheter (BIC) technique. SpyGlass™ Discover choledochoscopy showed a clear distal CBD and a large 12mm stone in the common hepatic duct. The stone was hard and required a high setting of lithotripsy (30, Max). The stone was fragmented successfully, and all fragments extracted using baskets. The cystic duct was closed by suturing using 3.0 Vicryl and two Robinson abdominal drains were left in the abdomen; one in Morrison's pouch and one in the sub-diaphragmatic space. The patient had an uncomplicated post-operative recovery and was discharged home after 5 days. Follow-up 8 months later was satisfactory. Conclusions Trans-Cystic bile duct exploration has become increasingly safe and feasible even for large bile duct stones using new technology. ERCP should be avoided in young fit patients, especially females due to the higher risk of post-ERCP pancreatitis.

The Laparoscopic Cholecystectomy and Common Bile Duct Exploration: A Single-Step Treatment of Pediatric Cholelithiasis and Choledocholithiasis.

Background: In recent years, complicated biliary tract diseases are increasingly diagnosed in children. Laparoscopic exploration of the common bile duct (LCBDE) followed by laparoscopic cholecystectomy has gained popularity in children. The aim of this study was to investigate the outcomes of LCBDE in children and compare them with the treatment outcomes of previously used endoscopic retrograde cholangiopancreatography (ERCP). Methods: From January 2000 to January 2022, a total of 84 children (78.5% female) underwent laparoscopic cholecystectomy with a median follow-up of 11.4 (IQR 8, 14) years. Of these, 6 children underwent laparoscopic cholecystectomy (LC) + ERCP and 14 children underwent LCBDE for choledochiothiasis. The primary end point of the study was the success of treatment in terms of the incidence of complications, recurrence rate, and rate of reoperation. Secondary endpoints were stone characteristics, presenting symptoms, duration of surgery, and length of hospital stay. Results: The majority of patients were female in both groups (83.5% vs. 85.7%), mostly overweight with a median BMI of 27.9 kg/m2 and 27.4 kg/m2, respectively. Obstructive jaundice, colicky pain, acute pancreatitis, and obstruction of the papilla were the most common symptoms in both groups. The majority of patients (68%) had one stone, whereas two or more stones were found in 32% of patients. The median diameter of the common bile duct was 9 mm in both groups. The procedure was successfully completed in all patients in the ERCP group. In the group of patients treated with LCBDE, endoscopic extraction of the stone with a Dormia basket was successfully performed in ten patients (71.4%), while in the remaining four patients (28.6%) the stones were fragmented with a laser because extraction with the Dormia basket was not possible. The median operative time was 79 min in the LCBDE group (IQR 68, 98), while it was slightly longer in the ERCP group, 85 min (IQR 74, 105) (p = 0.125). The length of hospital stay was significantly shorter in the LCBDE group (2 vs. 4 days, p = 0.011). No complications occurred in the LCBDE group, while two (40%) complications occurred in the ERCP group: pancreatitis and cholangitis (p = 0.078). During the follow-up period, no conversions, papillotomies, or recurrences were recorded in either group. Conclusions: Exploration of the common bile duct and removal of stones by LCBDE is safe and feasible in pediatric patients for the treatment of choledocholithiasis. Through this procedure, choledocholithiasis and cholelithiasis can be treated in a single procedure without papillotomy or fluoroscopy. Compared with LC + ERCP, LCBDE is associated with a shorter hospital stay. The incidence of complications was rather low but not statistically significant.

Leveraging access to technology and enhanced surgical technique (LATEST) in laparoscopic bile duct exploration (LBDE)

Single-stage management of choledocholithiasis with concomitant gallstones consists of performing either laparoscopic bile duct exploration (LBDE) or intra-operative endoscopic retrograde cholangiopancreatography at the same time as laparoscopic cholecystectomy. Transductal LBDE is associated with significantly higher post-operative morbidity, longer operative times and longer hospital stay when compared to transcystic LBDE. The aim of this study was to report the transcystic exploration rate and post-operative outcomes from LBDE before and after implementation of the LATEST (Leveraging Access to Technology and Enhanced Surgical Technique) principles. Methods: A retrospective review of 481 consecutive patients between February 1998 and July 2021 was performed. Patients were assigned into two groups determined by whether they were operated before or after the implementation of LATEST. Data collected included pre-operative demographic information, medical co-morbidity, pre-operative investigations, and intra-operative findings (including transcystic exploration rate, negative choledochoscopy rate, use of holmium laser lithotripsy and operative time). Outcomes of this study were the transcystic exploration rate, stone clearance rate, conversion to open surgery, post-operative morbidity and mortality, and length of post-operative hospital stay. Results: The pre-LATEST group contained 237 patients and the LATEST group comprised of 244 patients. Ultra-thin choledochoscopes and holmium laser lithotripsy were used more frequently in the LATEST group (41.4% and 18.4%, respectively). Enhanced surgical techniques (correction of the cystic duct-CBD junction and the trans-infundibular approach) were also performed more frequently in the LATEST group. More patients in the LATEST group received transcystic LBDE (86.1% vs 11.0%, p < 0.0001). The LATEST group had significantly higher stone clearance rates (98.8% vs 93.7%, p = 0.0034), reduced post-operative morbidity and shorter post-operative hospital stay (4 days vs 1 day, p < 0.0001). Conclusions: LATEST describes four key factors that can be used when performing LBDE. The adoption of LATEST in LBDE is associated with an increased stone clearance, a higher transcystic exploration rate and reduced post-operative morbidity.

Innovative choledochoscope for simulation based training in resource limited setting.

Intraoperative choledochoscopy is on the rise. Simulated training is essential for proper handling of the instrument during laparoscopic bile duct exploration. The article describes a low budget innovative choledochoscope for simulated training in low resource setting.

The single-stage management of bile duct stones is underutilised: A prospective multicentre cohort study with a literature review.

Bile duct stones (BDS) can be managed either prior to laparoscopic cholecystectomy (LC) using endoscopic retrograde cholangiopancreatography (ERCP) or with laparoscopic bile duct exploration (LBDE) at the time of LC. The latter is underutilised. The aim of this study was to use the dataset of the previously performed CholeS study to investigate LBDE hospital volumes, LBDE-to-LC rates, and LBDE outcomes. Data from 166 United Kingdom/Republic of Ireland hospitals were used to study the utilisation of LBDE in LC patients. Of 8,820 LCs performed, 932 patients (10.6%) underwent preoperative ERCP and 256 patients (2.9%) underwent LBDE. Of the 256 patients who underwent LBDE, 73 patients (28.5%) had undergone prior ERCP and 112 patients (43.8%) had undergone prior magnetic resonance cholangiopancreatography. Fifteen (9.0%) of the 166 included hospitals performed less than five LBDEs in the two-month study period. LBDEs were mainly performed by upper gastrointestinal surgeons (84.4%) and colorectal surgeons (10.0%). Eighty-seven percent of the LBDEs were performed by consultants and 13.0% were performed by trainees. The laparoscopic-to-open conversion rate was 12.5%. The median operation time was 111 minutes (range: 75-155 minutes). Median hospital stay was 6 days (range: 4-11 days) for emergency LBDEs and 1 day (range: 1-4 days) for elective LBDEs. Overall morbidity was 21.5%. Bile leak rate was 5.3%. Thirty-day readmission and mortality rates were 12.1% and 0.4%, respectively. The single-stage approach to managing BDS was underutilised. An additional prospective study with a longer study period is needed to verify this finding.