Laparoscopic Bile Duct Exploration Research Articles

BN SO52 - Innovative Tools for Laparoscopic Bile Duct Exploration (LCBDE) in Torbay Hospital

Abstract Background Laparoscopic bile duct exploration (LCBDE) is a minimally invasive technique used to manage common bile duct (CBD) stones. The procedure has evolved significantly with the development of specialized tools that enhance efficacy and patient outcomes. This abstract aims to discuss the various tools employed for LCBDE at Torbay Hospital, highlighting their specific uses, benefits, and outcomes. Method We conducted a retrospective analysis of LCBDE procedures performed at Torbay Hospital. The tools used included the Pusen ‘Skinny scope’, Ambscope, Nathenson tipless basket, GB stone retrieval basket, and Rotacrusher. Data were collected on the types of tools used, procedural success rates, stone clearance rates, and any complications Results The Pusen ‘Skinny scope’ (3mm) was used in 60% of cases for transcystic exploration, showing high success in stone visualization and retrieval. The Ambscope (5mm) was used in 30% of cases for choledochotomy, effectively accessing larger stones. The Nathenson tipless basket retrieved up to 8mm stones in 45% of cases. The GB stone retrieval basket extracted non-disposable stones up to 2cm. The Rotacnsher, used for large stones in choledochotomy, was highly effective but needed larger port access. Laser and mechanical lithotripters fragmented stones larger than 1cm with an 85% success rate. Overall stone clearance was 90% with minimal complications. Conclusion The use of specialized tools in LCBDE at Torbay Hospital has significantly improved the management of CBD stones. The Pusen ‘Skinny scope’ and Ambscope provide excellent visualization and access, while the Nathenson tipless basket and GB stone retrieval basket offer reliable stone extraction capabilities. Advanced lithotripters further enhance the ability to manage larger stones. These tools collectively contribute to high success rates and favorable patient outcomes, reinforcing the value of LCBDE in modern surgical practice.

VS 09 - HPB Laparoscopic Trans-Cystic Bile Duct Exploration is Safe and Feasible even after previous Cholecystectomy

Abstract Background Laparoscopic trans-cystic bile duct exploration is well know to have less comorbidity that conventional trans-ductal approach. A 56-year-old female underwent emergency laparoscopic cholecystectomy in 2019 for cholecystitis. Subsequently treated conservatively for ascending cholangitis due to large stone in the bile duct on MRCP. She underwent two unsuccessful ERCPs due to anatomical challenges; large hiatus hernia and duodenal diverticulum. The MDT determined bile duct exploration was necessary as no endoscopic options remained. After assessing previous imaging, laparoscopic trans-cystic exploration was chosen to minimise complications. This video highlights the feasibility of laparoscopic trans-cystic CBD post-cholecystectomy. Method Standard four-port technique with 10mm, 30-degree laparoscope. Blunt, sharp, energised and hydro-dissection were employed. Indocyanaine green(ICG) helped identify the bile duct(CBD) and the cystic duct(CD) stump. CD was dissected from the gallbladder bed and opened for a cholangiogram; confirming a large stone in the distal bile duct. A 3.5 mm choledochoscope with electrohydraulic lithotripsy(EHL) was used to explore the bile duct and fragment the stone for extraction. Remaining small fragments were flushed into the duodenum after 20mg buscopan intravenously. Final cholangioscopy and cholangiogram through the choledochoscope showed clear ducts with good flow into the duodenum. Results The patient was started on IV antibiotics due to pyrexia on the first night of admission. The abdominal drain was removed after 48 hours, and the patient was discharged on day three to complete a five-day course of antibiotics. Nine months post-operatively, she presented with a 3x5x7.5 cm sub-hepatic abscess, requiring interventional radiology (IR) drainage and a six-week course of antibiotics. The drain was removed after a follow-up CT scan three weeks post-drainage showed resolution. There have been no further episodes of cholangitis, and she has returned to her baseline quality of life. Conclusion This case shows laparoscopic trans-cystic approach remains viable post-cholecystectomy. Advanced imaging and tools including 3.5mm choledochoscope and EHL aid safer surgery with reduced morbidity, shorter stays and faster recovery. Antibiotics may be necessary for cases with longstanding bile duct stones. Furthermore, this case highlights the importance of intraoperative cholangiography and bile duct exploration. The patient had an MRCP in 2019 that showed no bile duct stones but a dilated CBD associated with deranged LFTs. This suggests that her journey might have been less complicated if a cholangiogram had been performed during the initial laparoscopic cholecystectomy.

HPB SO37 - GTN Patch for Medical Relaxation of the Sphincter of Oddi: “A Safe and Effective Pre-ERCP Treatment for Controlled Bile Leak Post-Cholecystectomy"

Abstract Background Bile leak is a frequent complication following laparoscopic total, subtotal cholecystectomy, and bile duct exploration (BDE) with an incidence up to 2.8%. It can contributing significantly to postoperative morbidity and mortality. GTN has demonstrated efficacy in reducing papillary muscle contraction and Sphincter of Oddi pressure. Similarly GTN might promote healing and closure of bile leaks post total or subtotal cholecystectomy. This study aims to assess the safety and effectiveness of GTN in treating bile leaks post total, subtotal cholecystectomy or bile duct exploration. Method Data was prospectively collected from patients who developed bile leaks after total or subtotal cholecystectomy between June 2020 and June 2024. Inclusion criteria were patients with a bile leak post-surgery during this period. Exclusion criteria included unstable patients, uncontrolled bile leaks, the presence of biliary obstruction, or major bile duct injuries. Suitable patients were treated with a GTN patch as first line management before potential ERCP. A 5 mg GTN skin patch was applied every 24 hours, starting at least 48 hours post-surgery if drain output exceeded 100 ml/hour. Patients were consented about side effects including hypotension and headache. Results Seven patients were treated with GTN, with mean age of 51 years, four were females. Four cases were emergencies and four had subtotal cholecystectomies, one in the elective group. Bile leaks occurred after biloma drainage and one after removal of trans-cystic drain post trans-cystic BDE. All patients experienced significant drain output reduction the day after starting GTN. There were no complications during or after treatment. One required ERCP two months later for persistent low-volume bile leak of 5-10 ml per day. Headaches occurred in two cases, treatment was discontinued in one. The average time to GTN treatment was 3.4 days. Conclusion This study demonstrates GTN treatment's safety and effectiveness for managing bile leaks following total, subtotal cholecystectomy or BDE. We recommend GTN as the primary therapy for controlled bile leaks, barring biliary obstruction or major injury. Response can be evaluated within 24-48 hours through significant output reduction. Implementing local protocols can minimize variations in GTN treatment initiation times. GTN should be prioritized over ERCP to prevent complications like perforation, pancreatitis, and bleeding. We aim for this study to underscore GTN's efficacy to surgeons and promote multicentre research initiatives.

HPB SO59 - How do Previous Biliary Interventions Affect the Operative and Postoperative Outcomes Of Patients Undergoing Laparoscopic Cholecystectomy (LC) and Bile Duct Exploration (LCBDE)?

Abstract Background Laparoscopic biliary surgery is perceived to be difficult in patients who had undergone previous biliary interventions; ERCP, cholecystostomy or cholecystectomy. Our objective was to evaluate the referral pattern, the preoperative characteristics and operative and postoperative outcomes in such patients. Method Analysis of prospectively collected data from patients treated by a specialist biliary unit dedicated to index admission LC and single session laparoscopic management of bile duct stones. In spite of a policy of no preoperative endoscopic clearance of bile duct stones the unit inevitably received some patients who had had previous ERCP at other hospitals prior to referral or were initially unfit when admitted to the base hospital and required ERCP. In a series of 6140 LC and LCBDE 158 patients (2.57%) had already undergone ERCP and 31 (0.5%) had undergone cholecystectomies (18), cholecystostomies (9) or attempted cholecystectomy. Results Of 158 pre-referral ERCPs, 130 (82.3%) were referred from other hospitals, 36 (22.8%) having had more than one ERCP. 83.5% had suspected CBD stones. LC difficulty grade was IV to V in 48.7%. 112 patients (70.9%) required LCBDE. There were 10.1% biliary related complications, 3 re-operations, one conversion and one mortality. of 31 patients with previous biliary interventions, 58% came from other units or hospitals. A third had already undergone ERCP. 61.3% had LC difficulty grades IV or V. The 18 un-cholecystectomised patients needed LCBDE with no conversions or bile duct injuries. There were only 2 (6.5%) biliary related complications. Conclusion While previous biliary interventions understandably increased the difficulty of LC they did not adversely affect operative and postoperative outcomes. Such surgery should be undertaken in the specialist setting as 70.9% of those with previous endoscopic and 58.1% of those with previous surgical or radiologically guided biliary interventions require LCBDE. Implementing definitive surgical interventions during the index admission can achieve a substantial reduction in re-admission rates, and overall decrease in hospital episodes without significant morbidity, re-interventions or mortality. This enhances the quality of life for patients who would otherwise be subjected to multiple repeat ERCPs and yields significant cost benefits.

Structured learning and mentoring: shortening the learning curve in laparoscopic common bile duct exploration.

Technological advances have made the laparoscopy procedure popular for simultaneous cholecystectomy and bile duct exploration. We aimed to assess the implementation of a structured mentorship program for training in laparoscopic common bile duct exploration (LCBDE). We explored the effectiveness thereof in facilitating the learning of LCBDE as a single-stage treatment of common bile duct stones (CBD) with gallbladder in situ. The surgical databases of a mentor (experienced in LCBDE) and a mentee (new to LCBDE) were analyzed. The analysis retrospectively compared the mentor's first 100 cases (MF) with the mentee's first 100 (MEF) cases, and the mentor's last 100 cases (ML) with the mentee's initial cases. Data included demographics, technical details, and postoperative outcomes. A total of 300 patients underwent LCBDE. For MF vs. MEF (both n = 100), MF had a lower transcystic approach rate (5% vs. 70%; p < 0.001) than MEF. Postoperative median hospital stay was significantly shorter in the MEF group compared to the MF group (2 vs 5, p < 0.001). No mortality or significant complications were observed in either group. For ML (n = 100) vs. MEF, the ML group had a higher transcystic rate (87% vs. 70%; p = 0.005). No differences in mortality or conversion were observed between the groups. Bile leak was lower in the ML (3% vs. 6%, p = 0.498) group than the MEF group. Postoperative median hospital stay did not significantly differ between the ML and MEF group (1 vs 2days, p = 0.952). Structured mentorship significantly influenced the successful adoption of LCBDE by the mentee, shortening the learning curve to provide outcomes in the first 100 cases, comparable to highly experienced centers. These results support the implementation of structured training and continuous mentoring to facilitate the learning curve of laparoscopic bile duct exploration.

Comparative study of Indocyanine Green fluorescence imaging versus conventional fiber-optic imaging in laparoscopic choledochotomy for stone extraction and immediate biliary incision suturing.

To explore the Advantages of Indocyanine Green (ICG) Fluorescence Imaging over Conventional Fiber-Optic Imaging in Laparoscopic Cholangiography and Immediate Suture for Stone Removal. The study is a randomized controlled descriptive research. Consecutive patient data were collected from October 2022 to January 2024 at the Second People's Hospital of Chengdu for those who underwent laparoscopic bile duct exploration and stone removal, totaling 72 cases. According to the order of admission, they were randomly assigned to either the study group or the control group, with 36 cases in each group. Ten minutes preoperatively, indocyanine green (ICG) was administered intravenously through a peripheral vein to the subjects in the study group, to enable real-time fluorescent tracing of the extrahepatic bile ducts during surgery. This study compares the efficiency of bile duct structure and boundary recognition, the timeliness of bile duct incision positioning, operative time, blood loss, and the incidence of bile duct injury between patients who were injected with ICG and those who were not. In addition, it assesses liver function and white blood-cell counts rechecked 24h postoperatively, the duration of postoperative hospital stay, and the occurrence of bile leakage. The study included 72 patients, with 36 in the indocyanine green (ICG) fluorescence group and 36 in the conventional fiber-optic group, comprising 26 males and 46 females. There were 18 patients with a history of previous biliary exploration surgery and 23 who had undergone previous cholecystectomy. During surgery, ICG fluorescence was successfully visualized in all 36 cases of the ICG group, allowing for a clear view of the anatomical structure and boundaries of the extrahepatic bile ducts. Compared to the control group, the ICG fluorescence group demonstrated a reduction in the time required for identification of the biliary system and positioning of the bile duct incision, as well as a decrease in operative time and postoperative hospital stay; intraoperative blood loss and the incidence of bile leakage were also relatively reduced, with statistically significant differences (P < 0.05). However, there were no statistically significant differences in postoperative serum alanine aminotransferase levels, white blood-cell counts, direct bilirubin, and indirect bilirubin between the two groups (P > 0.05). One case of bile duct injury occurred in the control group. The application of ICG fluorescence navigation in laparoscopic cholecystectomy can effectively enhance the visibility of the bile ducts, rapidly identify the location for bile duct incision, and is conducive to reducing both the duration of surgery and postoperative hospital stay. It also minimizes intraoperative blood loss, prevents bile leakage and bile duct injuries. This program has demonstrating significant clinical value.

ThP4.12 - Impacted Bile Duct Stones Encountered during 1447 Laparoscopic Explorations; Incidence and Management

Abstract Aim To study the incidence and management of impacted bile duct stones encountered during laparoscopic bile duct exploration (LCBDE). Methods A review of patients undergoing LCBDE for impacted stones. Preoperative imaging, operative difficulty grading, impaction location, dis-impaction methods, operative complications and postoperative outcomes were analysed. Results 136 of 1447 (9.4%) LCBDEs had impacted stones; median age 53 years, 63.2% females. 88.2% were emergencies; 94 Jaundiced (69.1%). USS showed CBD dilatation in 30.1%. 16.9% had previous ERCP and 43% previous biliary admissions. CBD exploration was transcystic in 52 (38.2%) and via choledochotomy in 84 (61.8%). LCBDE difficulty grading was IV in 61 (44.9%) and V in 75 (55.1%). The number of stones ranged from 1-70 (mean 6, median 2) and stone size 4-30mm (median 12). All needed choledochoscopy. Impaction was at lower CBD in 83 (61%), Mid-CBD 29 (21.3%), Intra-hepatic 15 (11%), intra and extra hepatic in 6 (4.4%) and intramural in 3. Dis-impaction needed biopsy forceps/grasper fragmentation (45.6%) basket/Fogarty manipulation in 35.3%, laser in 8.8%, pushing stones using the choledocoscope in 6 cases (4.4%) and conversion or leaving stone for ERCP in 7 (5.8% 6 prior to1997). The median operative time was 150 minutes (60-630 minutes). Complications occurred in 33 (24.2%) including15 biliary-related and 9 biliary drain-related. Readmissions occurred in 18 patients (11 biliary-related) and one death was caused by pneumonia. Hospital stay median was 10 days (3 to 54). On 80% follow up the presentation to resolution period median was 2 weeks (1- 30). Conclusions Apart from CBD stones shown on USS and failed ERCP this study identified no obvious risk factors.

ThP4.13 - To drain or not to drain?! Selective Abdominal Drainage Reduces Morbidity and Re-interventions in Laparoscopic Cholecystectomy and Bile Duct Exploration

Abstract Aims To evaluate the indications and benefits of sub-hepatic drainage after laparoscopic cholecystectomy(LC) and bile duct exploration (LCBDE). Methods Utilisation of drains in a prospective database of LC and LCBDE was reviewed. The occurrence of postcholecystectomy bile leakage (PCBL) and abdominal collections was analysed. Results 52.5 % of 6140 patients had drains. PCBL occurred in 43 (1.3%). 20 leaks had choledochotomy LCBDE; 16 before drain removal (10 settling spontaneously, 3 requiring ERCP, 3 relaparoscopy). All 4 occurring after drain removal required percutaneous drains (PCD) or ERCPs. 12 leaks had transcystic explorations; 10 before drain removal (8 settling spontaneously, 1 ERCP, 1 PCD) and 2 after drain removal (1 settled, 1 needed ERCP). 11 PCBLs had LC only; 9 still had drains (6 settled, 1 PCD, 1 ERCP, 1 relaparoscopy) and 2 after drain removal needing relaparoscopy and ERCP. Drains allowed early detection and spontaneous resolution in 24 patients (55.8%) and early detection and intervention prevented serious morbidity in 11 (25.6%). 7 of 8 PCBLs after drain removal required reintervention. 2915 (47.5%) had no drains. 6 had PCBL (0.2%); 5 needing multiple reinterventions; 3 PCD, 2 ERCPs and 3 relaparoscopies. Drains caused complications in six patients (0.18%); one retracted into the abdomen needing relaparoscopy, two drain site infections and 3 had significant pain disappearing when drains were removed. Collections other than PCBL occurred in 19 patients; 8 with drains and 11 after drain removal. They were treated conservatively (9), by PCD (8) or relaparoscopy (2). Conclusions Careful selective abdominal drainage after advanced biliary surgery allows early detection of collections, minimising morbidity and reintervention.

ThP6.2 - Benign and malignant biliary strictures encountered during single session laparoscopic cholecystectomy and bile duct exploration. Rationalising preoperative imaging and relying on routine cholangiography can optimise outcomes

Abstract Aim To review causes, diagnostic features and operative strategies of biliary strictures discovered on routine cholangiography (IOC) during single session treatment of bile duct stones. Methods A prospective database of cholecystectomies and bile duct explorations spanning 30 years was analysed. Cross sectional imaging and ERCP play a limited role in patients with confirmed gall stones except in suspected malignancies. Results 53/6140 patients (0.86%) had strictures on IOC.Malignant Strictures 27 (%)Benign strictures 26 (%)Females18 (66.6)12 (46)Age Median7262Emergency admission24 (88.8)15 (57.7)Presentation: Jaundice22 (81.5)15 (57.7)USS: GB Thick or contracted6 (22.2)4 (15.4)Bile duct dilatation16 (59.2)14 (53.8)Suspected CBD stones23 (85.2)24 (92.3)Preoperative imaging: MRCP1 (3.7)6 (23)CT6 (22.2)4 (15.4)ERCP1 (3.7)5 (19.2)Gall bladder conditionMucocele10 (37)3 (11.5)Acute/Empyema6 (22.2)4 (15.4)Contracted5 (18.5)9 (34.6)Cholangiography abnormality:Strictures + dilated ducts12 (44.4)22 (84.6)Dilated ducts/stones/no flow15 (55.5)4 (15.4)Bile Duct Exploration:Choledochotomy17 (63)10 (38.4)Transcystic5 (18.5)11 (42.3)NONE5 (18.5)5 (19.2)Choledochoscopy21 (77.7)20 (76.9)Biliary drains13 (48)18 (69)Stents9 (33.3)3 (11.5)Operative time (median)135 min135Open conversion1 Bilioenteric anastomosis0Morbidity4 (14.8)7 (26.9)Hospital stay median1413Postoperative ERCP11 (40.7)11 (42.3)Postoperative surgery322 year survival122 Conclusions Careful clinical assessment and exclusion of risk of malignancy optimises preoperative imaging and maximise benefits of single session management of suspected CBD stones.

SP4.1 - Incidence of recurrent bile duct stones following 6140 laparoscopic cholecystectomies and bile duct explorations: management and evaluation of risk factors

Abstract Aim To evaluate the rate of bile duct stone recurrence and possible risk factors in patients undergoing laparoscopic cholecystectomy (LC) and bile duct exploration (LCBDE) on a unit adopting routine cholangiography and LCBDE. Methods A prospective database of LC and LCBDE with confirmed ductal clearance spanning 30 years was reviewed. Those returning with clinical and laboratory suspicion of recurrence were included whether or not MRCP confirmation was obtained or intervention required. Apart from annual follow up electronic records were examined in 2020 and 2023 to capture unreported episodes. Results 1447 patients underwent LCBDE. 56 (3.8%) had suspected recurrence after a mean of 36.6 months (5-144). Mean age was 67.6 years and 57.1% were females. 12 (21.4%) settled on conservative management, including Glucagon administration, and MRCP was negative. 44 patients (78.6%) had 59 confirmed recurrence episodes; 53 needing 63 ERCPs and 6 settling conservatively. 12/44 (21.4%) had repeat recurrences. Only one biliary-enteric anastomosis was required. Only 11 of 4693 LC (0.23%) had recurrent stones (5 repeatedly) after a median interval of 30 months (5-120). 19 recurrence episodes occurred during which 13 settled spontaneously and 6 needed 9 ERCPs. In spite of average rates of ERCP morbidity no biliary related deaths resulted from stone recurrence. Compared to the rest of LCBDEs those with recurrence were more male, older, with more dilated CBD on USS &amp; required more choledochotomies for larger stones. Conclusions CBDS recurrence occurs in 3.8% after LCBDE with 3% confirmed and requiring intervention, significantly lower than after sphincterotomy. Glucagon may help small stones pass. 21.4% have repeat recurrences justifying stone dissolution agents. Identifying recurrence risk factors require further studies.

A novel 3D-printed educational model for the training of laparoscopic bile duct Exploration:a pilot study for beginning trainees

BackgroundLaparoscopic common bile duct exploration (LCBDE) is a minimally invasive procedure for the removal of bile duct stones that is often performed by experienced hepatobiliary surgeons; beginners do not easily master this approach. AimTo investigate the effectiveness and practicality of a three-dimensional printed (3DP) anatomical model based on radiographic images in the training of LCBDE techniques and formulate standardized educational workflows. MethodsColored LCBDE training models were produced using 3DP technology. Twenty standardized training trainees were randomly divided into two groups: a 3DP model training group and a traditional laparoscopic simulation training group. Both groups received the same number of teaching hours. After a 4-weeks training course, the trainees’ subjective and objective progress in basic knowledge and manipulations were evaluated and compared. ResultsCompared with traditional laparoscopic simulation, 3DP model simulation training is of great significance in improving trainers' understanding of surgical procedures and cooperation during the operation. Trainees with 3DP models training demonstrated a significant improvement in their understanding of the key points of surgery (χ2 = 6.139, p = 0.013) and skills scores, especially in core procedural steps operation. More importantly, the trainees showed higher levels of satisfaction and self-confidence while assisting in the surgery. ConclusionWith the development of 3DP models, improvements in the learning effect for theoretical understanding and practical skills were significant. The present study is the initial educational experience with 3DP models to facilitate the operational capabilities of the trainees for LCBDE.

Role of indocyanine green-guided near-infrared fluorescence imaging in identification of the cause of neonatal cholestasis.

To evaluate the efficacy and safety of indocyanine green (ICG)-guided near-infrared fluorescence (NIRF) imaging during surgery to diagnose the cause of neonatal cholestasis (NC). Data on NC patients who underwent both NIRF with ICG and conventional laparoscopic bile duct exploration (the gold standard) at our institute from January 2022 to December 2022 were retrospectively analyzed. The patients' baseline characteristics and liver function outcomes were collected and analyzed, and the diagnostic consistency was compared between the 2 methods. In total, 16 NC patients were included in the study, comprising 8 (50%) male and 8 (50%) female patients, ranging in age from 42 to 93 days, with a median age of 54.4 ± 21 days. During surgery, all the patients underwent NIRF with ICG, followed by conventional laparoscopic bile duct exploration. Finally, 15 of the patients were diagnosed with biliary atresia (BA) (1 with type-I BA, and 14 with type-II BA). The other patient was diagnosed with cholestasis. The diagnostic results from fluorescence imaging with ICG were consistent with those from conventional laparoscopic bile duct exploration. ICG-guided NIRF is associated with an easy operation, less trauma, and good safety. Also, its diagnostic accuracy is similar to conventional laparoscopic bile duct exploration.

The effects of previous abdominal surgery and the utilisation of modified access techniques on the operative difficulty and outcomes of laparoscopic cholecystectomy and bile duct exploration

BackgroundEarly reports suggested that previous abdominal surgery was a relative contraindication to laparoscopic cholecystectomy (LC) on account of difficulty and potential access complications. This study analyses different types/systems of previous surgery and locations of scars and how they affect access difficulties. As modified access techniques to minimise risk of complications are under-reported the study details and evaluates them.MethodProspectively collected data from consecutive LC and common bile duct explorations (LCBDE) performed by a single surgeon over 30 years was analysed. Previous abdominal surgery was documented and peri-operative outcomes were compared with patients who had no previous surgery using Chi-squared analysis.ResultsOf 5916 LC and LCBDE, 1846 patients (31.2%) had previous abdominal surgery. The median age was 60 years. Those with previous surgery required more frequent duodenal (RR 1.07; p = 0.023), hepatic flexure (RR 1.11; p = 0.043) and distal adhesiolysis (RR 3.57; p < 0.001) and had more access related bowel injuries (0.4% vs. 0.0%; p < 0.001). Previous upper gastrointestinal and biliary surgery had the highest rates of adhesiolysis (76.3%), difficult cystic pedicles (58.8%), fundus-first approach (7.2%), difficulty grades (64.9% Grades 3–5) and utilisation of abdominal drains (71.1%). Previous open surgery resulted in longer operative time compared to previous laparoscopic procedures (65vs.55 min; p < 0.001), increased difficulty of pedicle dissection (42.4% vs. 36.0%; p < 0.05) and required more duodenal, hepatic flexure and distant adhesiolysis (p < 0.05) and fundus-first dissection (4% vs 2%; p < 0.05). Epigastric and supraumbilical access and access through umbilical and other hernias were used in 163 patients (8.8%) with no bowel complications.ConclusionThe risks of access and adhesiolysis in patients with previous abdominal scars undergoing biliary surgery are dependent on the nature of previous surgery. Previous open, upper gastrointestinal and biliary surgery carried the most significant risks. Modified access techniques can be adopted to safely mitigate these risks.Graphical abstract

Minimally Invasive Common Bile Duct Stone Management in Gastric Bypass Patients: Laparoscopic Common Bile Duct Exploration with Disposable Bronchoscope.

Bariatric surgery patients may develop common bile duct stones, and the alterations in their anatomy present challenges in treating this condition. Methods such as laparoscopic bile duct exploration is impractical in many healthcare facilities, due to the absence of a choledochoscope. This study assesses the feasibility of laparoscopic exploration of the common bile duct using a disposable bronchoscope in these individuals. The study involved 32 participants who had undergone gastric bypass surgery. These participants presented with both bile duct stones and bile ducts exceeding 8mm in diameter, diagnosed through either MRCP or cholangiography conducted during the surgery. Stone extraction was carried out through either choledotomy or transcystic routes using a disposable bronchoscope and endoscopic baskets. The patients' ages ranged from 27 to 66years, with a mean bile duct diameter of 11.6mm (SD 3.1mm). A 100% stone clearance rate was achieved for all patients. None of the patients required conversion to open surgery. No T-tubes were placed. One patient developed biloma and intra-abdominal abscesses, which were successfully treated with a percutaneous drain over the course of a week. No mortalities were recorded during the course of this study. Our study results demonstrate that laparoscopic bile duct exploration is both feasible and safe in patients who have undergone gastric bypass surgery. The utilization of a disposable bronchoscope emerges as a practical and cost-effective alternative to a choledochoscope in this procedure.

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.&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D; 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%.&#x0D;

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 (&gt;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.