Laparoscopic Choledocholithotomy Research Articles

A comparative study of laparoscopic choledocholithotomy with primary suture and T-tube drainage.

To investigate the clinical efficacy of laparoscopic choledocholithotomy with one-stage suture. The clinical data of 68 patients who underwent laparoscopic choledocholithotomy in our hospital from January 2015 to December 2021 were retrospectively analyzed. Among them, 29 patients underwent laparoscopic primary closure (PC group) and 39 underwent T-tube drainage (T-tube group). All patients were diagnosed with choledocholithiasis by B-ultrasound, CT or MRCP. The operation time, intraoperative blood loss, pain index, incidence of shoulder and back pain, postoperative satisfaction, postoperative bowel function recovery time, hospitalization time and expenses, and operation-related complications in the 2 groups were compared. 29 cases in PC group were successfully operated, and 39 cases in the T-tube drainage group (T-tube group) were successfully operated. The average operation time, postoperative bowel function recovery time, postoperative pain index, hospitalization time and expenses in PC group were significantly shorter or lower than those in T-tube group (P < .05) and the patient satisfaction in PC group was significantly higher than that in T-tube group (P < .05). In addition, the intraoperative blood loss and the incidence of surgical complications were similar between the 2 groups (P > .05). After laparoscopic common bile duct exploration, primary suture of common bile duct is a safe and effective treatment method, but the incidence of bile leakage is high, and clinical indications for surgery should be strictly controlled.

Primary Closure versus T-tube Drainage in laparoscopic Choledocholithotomy

Introduction: Choledocholithotomy followed by T-tube has long been a standard surgical treatment for choledocholithiasis. It is still a preferred choice in many hospitals where minimally invasive procedures are not feasible. The use of T-tube is not without complications. To avoid complications associated with T-tube, we have performed primary closure of the common bile duct (CBD) after exploration. This pilot study assessed the safety of primary closure of CBD, which would help form a basis for implementation on a wider scale. Aim of the study: To compare the outcome in primary closure of the common bile duct and T-tube drainage after choledocholithotomy. Methods: This cross-sectional study was conducted in the Department of Surgery at IBNSina Medical College &amp;Hospital, Dhaka, and Delta Medical College&amp; Hospital, Dhaka Bangladesh; from January 2021 to December 2022. A total of 80 patients were selected purposively, and were randomly divided into two groups: The t-tube drainage group and the primary closure group. Each group consisted of 40 patients. Data were entered and analyzed using SPSS software. Ethical clearance was obtained from the hospital's ethical review committee. Result: The most common presentation in the primary closure group was jaundice with 18 patients (45%) but most of the patients in the T-tube group presented with acute cholecystitis with 21 patients (52.5%).In primary closure patients the mean operating time was observed to be 60±15mins while that in the case of T-tube drainage patients was 90±10 mins. The total duration of hospital-stay in primary closure patients ranged from 6-10 days with an average duration of 8 days which was much shorter than that of T-tube drainage patients which ranged from 10-16 days with an average of 13 days. Conclusion: Primary closure following laparoscopic CBD exploration is safe and feasible for selected patients with choledocholithiasis. TAJ 2023; 36: No-2: 65-70

EFFICACY AND SAFETY OF PRIMARY CLOSURE OF COMMON BILE DUCT FOLLOWING LAPAROSCOPIC CHOLEDOCHOLITHOTOMY

Following surgical intervention for symptomatic cholelithiasis, approximately 10 to 15 percent of patients are diagnosed with choledocholithiasis, characterized by the presence of stones in CBD. Several surgeons perform open CBD exploration with primary duct closure. However, few surgeons perform duct closure laparoscopically due to technical difficulties and concerns about missed stones and postoperative complications. Thus, we evaluated the efficacy and safety of the primary closure of the common bile duct following laparoscopic choledocholithotomy. In this prospective observational study, 62 patients with CBD stones were confirmed pre-operatively by abdominal ultrasonography and/or magnetic resonance cholangiopancreatography (MRCP). CBD radiological findings and demographics were noted. Details on the intraoperative technique, overall operating time, and post-operative complications were observed. Patients were followed for one month, and post-operative data were collected and analysed. Most of the enrolled patients were female (69.35%), aged 41-50 (37.10%), and had abdominal pain (82.25%). 64.52% had multiple stones in the CBD of the calibre of 8–10 millimetres (40.32%). 94.52±21.58 mins was the mean operative time. CBD clearance was noted in 96.77% of cases. In most cases, intraoperative bleeding was 51–100 ml. Laparoscopic primary closure was performed in 96.77% of patients. On days 3 and 7, 9.68% and 6.45% of patients had bile leakage, respectively. The removal of abdominal drains varied significantly between cases. During the follow-up, two patients with bile leaks and jaundice after surgery were found to have retained stones and underwent post-operative ERCP without additional complications. The primary closure after LCBDE is considered a safe and effective alternative to T-tube drainage with an acceptable short-term outcome.

Laparoscopic Transcystic Common Bile Duct Exploration: 8-Year Experience at a Single Institution

BackgroundLaparoscopic transcystic common bile duct exploration (LTCBDE) is used to treat cholecystolithiasis and choledocholithiasis. This study aimed to investigate the safety, effectiveness and generalisability of LTCBDE in patients with cholecystolithiasis and choledocholithiasis based on our LTCBDE experience within 8 years. MethodsFour hundred patients with cholecystolithiasis and choledocholithiasis (including 62 of cholecystolithiasis and choledocholithiasis with common bile duct no-dilatation) treated with LTCBDE at a single centre from January 2014 to February 2022 were retrospectively evaluated. They were divided into the first 200 and last 200 LTCBDE cases. The disease characteristics, cystic duct incision methods, surgical outcomes and follow-up data were analysed retrospectively. Each patient was followed up for > 3 months. ResultsFour hundred patients underwent LTCBDE, including 188 males and 212 females aged from 15 to 91 years (average age: 56 years). LTCBDE was successful in 377 (94.3%) patients, while treatment was converted to laparoscopic choledocholithotomy with T-tube drainage in 23 (5.8%), owing to intraoperative choledochoscope insertion failure. The CBD diameter (10.89±1.76 vs 9.97 ± 2.39, P < 0.05), cystic duct diameter (4.62±1.03 vs 5.03 ± 1.29, P < 0.05), and operation time (164.60±24.30 vs 135.34 ± 30.00, P < 0.05). Residual stones were found in six (1.5%) patients and removed during the second operation; post-operative bile leakage was found in one (0.3%) patient, who was discharged safely after the second operation. ConclusionsPhase I LTCBDE is safe and effective in treating cholecystolithiasis and choledocholithiasis. With continuous technological advances, LTCBDE has been effectively promoted and applied.

Modern minimally invasive technologies for the treatment of cholelithiasis

Surgical community has not yet reached any consensus on the adequate treatment of gallstone disease with combined stones of the gallbladder and bile ducts. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic papillosphincterotomy (EPST) followed by laparoscopic cholecystectomy (LCE) have been considered the optimal treatment method for the past thirty years. Thanks to improvement of technologies and experience in laparoscopic surgery, many centers in the world offer simultaneous treatment of cholecystocholedocholithiasis, i.e. LCE and laparoscopic choledocholithotomy. Transcystical and transcholedochal extraction of calculi from the common bile duct is the most common. Intraoperative cholangiography and choledochoscopy are used to assess extraction of calculi while T-shaped drainage, biliary stent and primary suture of common bile duct are used to complete choledocholithotomy. Laparoscopic choledocholithotomy is associated with certain difficulties, requires some experience in choledochoscopy and intracorporeal suturing of common bile duct. There are many unresolved issues regarding the choice of laparoscopic choledocholithotomy technique depending on the number and dimensions of stones, diameter of cystic duct and common bile duct. The authors analyze literature data on the role of modern minimally invasive interventions in the treatment of gallstone disease.

Endoscopically non-removable stones of the common bile duct

To evaluate the effectiveness of long-term biliary stenting in the treatment of endoscopically intractable common bile duct stones. The study enrolled 247 patients with endoscopically non-removable bile duct calculi («difficult» choledocholithiasis) divided into two comparable groups. The main group included 129 patients who underwent biliary stenting with original stents with a nanocarbon inert coating (RF patent No. 84226), including those with inclusion of silver nanoclusters (RF patent No. 129397). The control group included 118 patients who underwent all methods of surgical treatment of choledocholithiasis, while biliary stents with original nanocarbon silver-containing inert coating were excluded. The vast majority of patients were women of advanced age (mean 66.8±4.7 and 66.3±5.6, max 89 and 90, min 32 and 37 years, respectively). In the control group, all patients underwent endoscopic transpapillary interventions as soon as possible. We could not extract common bile duct stones via endoscopic approach in 56.8% of cases. These patients underwent open or laparoscopic choledocholithotomy with lithoextraction. Complications occurred in 28.5% of cases. Mortality rate was 4.2%. Standard stenting of common bile duct was performed in 28.8% of cases. At the same time, stent dysfunction followed by relapse of obstructive jaundice occurred in 27.1% of patients within 3-3.5 months. Of these, 16 patients (13.5%) underwent stent removal and lithoextraction. Re-stenting was performed in 18 patients (15.3%). Moreover, shock wave lithotripsy with subsequent removal of common bile duct calculi was performed in 8 (6.8%) of these patients the next day. In the main group, original biliary plastic stents with nanocarbon silver-containing inert coating were implanted in all patients. Under permanent therapy with ursodeoxycholic acid drugs, we observed significant shrinkage of calculi to 11.8±1.8 mm and decrease in their density. This made it possible to carry out successful extraction of calculi in 81 patients (62.8%) after 6±0.3 months. Shock wave lithotripsy was performed in 36 (27.9%) cases. This procedure was successful and allowed final lithoextraction in 28 patients (21.7%). Re-stenting was performed in 15 (11.6%) cases, laparotomy - in 5 (3.9%) patients. Mortality rate was 0.78%. Our data allow us to discuss high efficiency of long-term bile duct stenting with plastic stents with nanocarbon silver-containing inert coating in complex treatment of choledocholithiasis. This approach ensures acceptable incidence of undesirable complications and mortality. This situation undoubtedly dictates the need for further larger prospective studies.

Laparoscopic lithotripsy and lithotomy of impacted stone at the terminal end of the common bile duct using a laparotomy biliary lithotomy spoon: A case report.

Introduction and importanceEndoscopic intervention is considered first-line therapy for common bile duct (CBD) stones, in recent times. However, surgically altered anatomy and consequent inaccessibility of the duodenal papilla necessitate surgery in some patients.Case presentationA 61-year-old woman presented with fever and right subcostal pain. She underwent total gastrectomy and Roux-en-Y reconstruction for gastric ulcer, 4 years prior to presentation. Based on the clinical findings, she was diagnosed with acute obstructive cholangitis secondary to a CBD stone. Endoscopic retrograde biliary drainage was attempted; however, the duodenal papilla was endoscopically inaccessible owing to the previous Roux-en-Y reconstruction, and we performed percutaneous transhepatic gallbladder drainage (PTGBD). She underwent laparoscopic cholecystectomy and choledocholithotomy, 6 days after the PTGBD. Choledocholithotomy was attempted using basket forceps under choledochoscopic guidance; however, this procedure was unsuccessful, and we performed laparoscopic choledocholithotomy using a laparotomy biliary lithotomy spoon.Clinical discussionUsually, laparoscopic cholecystectomy concomitant with CBD exploration is performed in patients with an endoscopically inaccessible duodenal papilla. However, an inadequately opened basket may not capture large impacted stones at the duodenal end of the CBD. Intraductal shock wave lithotripsy (electrohydraulic or laser lithotripsy) is considered in such cases; however, the specialized instruments required for this procedure are unavailable at all centers. Laparoscopic choledocholithotomy using a laparotomy biliary lithotomy spoon may be useful to overcome this surgically challenging situation.ConclusionA laparotomy biliary lithotomy spoon is a simple, user-friendly, and economical device that may be useful for laparoscopic lithotripsy and lithotomy of impacted stones.

Analysis of the curative effect of laparoscopic primary suture of common bile duct with two choledocholithotomy routes

Objective: To investigate the clinical efficacy of laparoscopic choledocholithotomy through cystic duct and common bile duct in the treatment of choledocholithiasis combined with cholecystolithiasis. Methods: 58 patients with choledocholithiasis complicated with cholecystolithiasis were selected. 26 cases were treated with choledocholithotomy through cystic duct approach and 32 cases were treated with direct choledocholithotomy. Laparoscopic combined choledochoscope or laparoscopic combined choledochoscope and duodenoscopy were performed with one-stage suture at the same time. The intraoperative diameter of common bile duct, duration of surgery, intraoperative blood loss, and length of hospital stay, drainage volume of abdominal drainage tube on the first day after surgery, extraction time of abdominal drainage tube, postoperative alanine transaminase, postoperative total bilirubin and incidence of postoperative complications were compared between the two groups. Results: Comparing the two groups of patients, the diameter of common bile duct P &lt; 0.05 was statistically significant. The surgical time, intraoperative blood loss, hospitalization time, abdominal drainage volume on the first day after surgery, drainage tube extubation time, postoperative alanine transaminase, postoperative total bilirubin, and complication rate were not statistically significant compared with P &gt; 0.05. Conclusion: According to the different diameter of choledocholithiasis, it is feasible to choose the appropriate path for laparoscopic primary suture of choledocholithiasis, which is worthy of further study.

AN ACCOUNT OF 15 YEARS EXPERIENCE OF LAPAROSCOPIC COMMON BILE DUCT EXPLORATION IN CHOLEDOCHOLITHIASIS FOLLOWED BY PRIMARY REPAIR AND ITS COMPARISON WITH OPEN CHOLEDOCHOLITHOTOMY IN DISHARI HEALTH POINT PRIVATE LIMITED, MALDA

A retrospective study of 4628 patients who underwent laparoscopic cholecystectomies with choledocholithotomy with primary repair of common bile duct , with a mean follow-up of 23.2 months is carried outto evaluate the safety and feasibility of laparoscopic choledocholithotomy via choledochotomy for the treatment of choledocholithiasis in Dishari Health Point Private Limited, a multispeciality hospital in Malda from January 2004 to January 2019. We had to convert to open surgery in 27 patients and could complete the operation laparoscopically in rest 4621 patients. We also did open surgery in 30 patients apart from this. We analyse the results and it was found that Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis.

Complications of Laparoscopic Choledochotomy and Lithotomy for Primary Suture

Objective: To explore the non-placement of “T�?tube after laparoscopic choledochotomy. feasibility and complication analysis of primary suture bile duct. Methods: Retrospective analysis of January 2013~ December 2016, Laparoscopic choledocholithotomy for primary bile duct suture in 87 cases, Combined with literature, the indications, methods and complications of the operation were summarized and analyzed. Results: There was no operative death in the whole group, Postoperative complications occurred in 5 cases (5.7%), 1 case with jaundice, gradually subsided after 4 days of conservative treatment. Two cases had postoperative bile leakage, to prolong the drainage time of the peritoneal drainage tube and stop by itself. In 1 case, bile duct stenosis occurred. 1 case of residual common bile duct stones. The average postoperative hospitalization was 9 days. Conclusion: Select the right case strictly, Patient and delicate operation, Laparoscopic choledochotomy is safe and feasible.

Analysis of 87 cases of laparoscopic choledochotomy with primary suture

To investigate the feasibility and clinical effect of laparoscopic choledochotomy for primary suture of bile duct. Methods: There were 190 cases of cholecystolithiasis with choledocholithiasis. They were randomly divided into endoscopic group and open group. In the endoscopic group ,87 patients underwent laparoscopic choledocholithotomy and primary bile duct suture. A total of 103 patients in open group were treated with open bile duct incision and T tube drainage. The operative time, intraoperative blood loss, postoperative ventilation time, hospital stay and postoperative complications were compared between the two groups. Results: The length of hospital stay, the amount of bleeding during operation and the time of postoperative ventilation were less than those in open group. The operation time was longer than that in open group, P &lt;0.01. There were 0 cases of postoperative incision infection ,2 cases of bile leakage and 1 case of residual stone in endoscopic group. The incidence of complications was 5.7%. The open group was 5,3,3 and 10.7% respectively. Comparison of complications between the two groups, P&lt;0.01. Conclusion: Select the right case strictly, Laparoscopic and choledochoscopy combined with cholecystolithiasis with choledocholithiasis is effective, safe and minimally invasive, short hospitalization time and less complications.

Efficacy of laparoscopic choledochotomy and T tube drainage for the patients of extrahepatic bile duct stones

Objective To observe the effect and quality of life score of laparoscopic choledochotomy and T tube drainage for the patients of extrahepatic bile duct stones. Methods A total of 80 patients with calculus of extrahepatic bile duct in Shandong Provincial Third Hospital from February 2016 to April 2017 were retrospectively analyzed, including 41 males and 39 females, among which, 40 patients were treated with laparoscopic choledocholithotomy and T tube drainage(the study group), and the other 40 cases were operated on laparotomy(the control group) by hierarchical randomization grouping. After operation, the time of operation, the amount of bleeding during the operation, the time of postoperative exhaust, the time of postoperative hospitalization and the difference of adverse reactions were observed in the two groups. Follow-up at the end of 1st and 3th month, quality of life score was compared between the two groups. The measurement data with normal distribution were expressed as mean±standard deviation (Mean±SD), comparison between groups were performed using t test. The count data were expressed as rate(%), comparison between groups were performed using chi-square test. Results Comparison of data between the study group and the control group: operation time respectively were (97.23±10.21) min, (117.52±10.01) min, the amount of bleeding respectively were(87.73±10.54) ml, (185.13±11.56) ml, postoperative exhaust time respectively were (17.57±2.96) h, (38.44±3.06) h and the postoperative hospitalization time were (7.75±1.21) d, (12.03±3.85) d. The data of each group in the study group were lower than those in the control group, and the difference was statistically significant(P 0.05). Conclusions Compared with open surgery, laparoscopic choledocholithotomy with T tube drainage has significant clinical effect in the treatment of extrahepatic bile duct stones. It can improve the quality of life and safety, and it is suitable for clinical application. Key words: Laparoscopes; Common bile duct; Cholelithiasis; Quality of life score; T tube drainage

Comprehensive and innovative techniques for laparoscopic choledocholithotomy: A surgical guide to successfully accomplish this advanced manipulation.

Surgeries for benign diseases of the extrahepatic bile duct (EHBD) are classified as lithotomy (i.e., choledocholithotomy) or diversion (i.e., choledochojejunostomy). Because of technical challenges, laparoscopic approaches for these surgeries have not gained worldwide popularity. The right upper quadrant of the abdomen is advantageous for laparoscopic procedures, and laparoscopic choledochojejunostomy is safe and feasible. Herein, we summarize tips and pitfalls in the actual procedures of choledocholithotomy. Laparoscopic choledocholithotomy with primary closure of the transductal incision and transcystic C-tube drainage has excellent clinical outcomes; however, emergent biliary drainage without endoscopic sphincterotomy and preoperative removal of anesthetic risk factors are required. Elastic suture should never be ligated directly on the cystic duct. Interrupted suture placement is the first choice for hemostasis near the EHBD. To prevent progressive laceration of the EHBD, full-layer interrupted sutures are placed at the upper and lower edges of the transductal incision. Cholangioscopy has only two-way operation; using dedicated forceps to atraumatically grasp the cholangioscope is important for smart maneuvering. The duration of intraoperative stone clearance accounts for most of the operative time. Moreover, dedicated forceps are an important instrument for atraumatic grasping of the cholangioscope. Damage to the cholangioscope requires expensive repair. Laparoscopic approach for choledocholithotomy involves technical difficulties. I hope this document with the visual explanation and literature review will be informative for skillful surgeons.

Near-Infrared Cholangiography Can Facilitate a Laparoscopic Choledocholithotomy Even After Upper Abdominal Surgery

Introduction: Surgery for common bile duct (CBD) stones is challenging while unclear hepatic hilum anatomy especial experience of previous laparotomy. A minimally-invasive approach choledocholithotomy can be difficult and converted for the unclear biliary anatomy. Near-infrared (NIR) cholangiography by systemic administration of Indocyanine Green (ICG) can enhance the visualization of the biliary tree anatomy but is limited by the high intensity of background fluorescence signal coming from the liver. NIR fluorescence cholecysto-cholangiography by direct biliary tree administration of the ICG can enhance the biliary tree without background noise signal. We created the NIR cholangiography via different route according to patient situation : systemic circulation or biliary tree injection to see the feasibility of those application Method: Ten patients who suffered from obstructive jaundice due to CBD stone and 5 patients received percutaneous biliary tree drainage as first treatment and 2 patients received endoscopic biliary tree drainage. Those patients received laparoscopic choledocholithotomy as definite treatment after acute infection phase. 5 patients received biliary tree ICG injection via drain tube and 5 patients by systemic injection. Visualization and fluorescence patterns around CBD was recorded Result: In our series, one patient received previous gastrectomy and 4 patients had previous biliary tree surgery. 2 Patients received PTGBD and 3 patient received PTCD for biliary decompression. The near infra-red cholangiography of ten patients can show the clear margin of CBD. No intra or postoperative complications noted. Median time to CBD localization after ICG injection was 5.2 sec for biliary tree injection and 35 minutes for systemic injection. One patient converted to open method due to big stone impaction in distal CBD. No mortality and mobidity were found. Conclusion: Fluorescence cholangiography with ICG injection could provide visualization of CBD even inflammatory or post operative adhesion status, and direct injection method provide more real-time and noise-free image than systemic injection.

A study of primary single and layered suture technique by using two-port laparoscopic choledocholithotomy.

Background:The aim of this study is to explore the application value of layered suture technique in two-port laparoscopic choledocholithotomy with primary suture.Materials and Methods:A prospective study of 267 patients received laparoscopic common bile duct choledocholithotomy with primary suture in our hospital from January 2014 to July 2017. Of these cases, layered suture technique was utilised in 110 patients, and single-suture technique was used in 157 patients. The operation time, post-operative hospital stay and post-operative complications were compared between the two groups.Results:Two groups of patients were operated smoothly, with no conversations to laparotomy. Post-operative recovery was symptom free. The operative time was not significantly different between the two groups of patients (t = −0.587, P = 0.086). The post-operative hospital stay and incidence of post-operative bile leakage were significantly lower in layered suture group than those in single-layer suture group ([7.6 ± 1.8] days vs. [5.8 ± 1.7] days, t = 2.776, P = 0.000; 4.5% [5/110] vs. 20.4% [32/157], χ2 = 9.885, P = 0.002). In the single-layer suture group, the incidence of post-operative bile leakage was significantly higher in patients complicated with acute cholangitis (44.4% [12/27] vs. 15.4% [20/130], χ2 = 11.634, P = 0.001), whereas in the layered suture group, the incidence of post-operative bile leakage was insignificantly different among patients with and without acute cholangitis (11.8% [2/17] vs. 3.2% [3/93], χ2 = 0.848, P = 0.357).Conclusion:Application of layered suture technique in laparoscopic choledocholithotomy with primary suture is feasible and safe, with advantages of less bile leakage and shorter hospital stay.

Laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy in people undergoing laparoscopic cholecystectomy for stones in the gallbladder and bile duct.

The management of gallbladder stones (lithiasis) concomitant with bile duct stones is controversial. The more frequent approach is a two-stage procedure, with endoscopic sphincterotomy and stone removal from the bile duct followed by laparoscopic cholecystectomy. The laparoscopic-endoscopic rendezvous combines the two techniques in a single-stage operation. To compare the benefits and harms of endoscopic sphincterotomy and stone removal followed by laparoscopic cholecystectomy (the single-stage rendezvous technique) versus preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy (two stages) in people with gallbladder and common bile duct stones. We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, Science Citation Index Expanded Web of Science, and two trials registers (February 2017). We included randomised clinical trials that enrolled people with concomitant gallbladder and common bile duct stones, regardless of clinical status or diagnostic work-up, and compared laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy procedures in people undergoing laparoscopic cholecystectomy. We excluded other endoscopic or surgical methods of intraoperative clearance of the bile duct, e.g. non-aided intraoperative endoscopic retrograde cholangiopancreatography or laparoscopic choledocholithotomy (surgical incision of the common bile duct for removal of bile duct stones). We used standard methodological procedures recommended by Cochrane. We included five randomised clinical trials with 517 participants (257 underwent a laparoscopic-endoscopic rendezvous technique versus 260 underwent a sequential approach), which fulfilled our inclusion criteria and provided data for analysis. Trial participants were scheduled for laparoscopic cholecystectomy because of suspected cholecysto-choledocholithiasis. Male/female ratio was 0.7; age of men and women ranged from 21 years to 87 years. The run-in and follow-up periods of the trials ranged from 32 months to 84 months. Overall, the five trials were judged at high risk of bias. Athough all trials measured mortality, there was just one death reported in one trial, in the laparoscopic-endoscopic rendezvous group (low-quality evidence). The overall morbidity (surgical morbidity plus general morbidity) may be lower with laparoscopic rendezvous (RR 0.59, 95% CI 0.29 to 1.20; participants = 434, trials = 4; I² = 28%; low-quality evidence); the effect was a little more certain when a fixed-effect model was used (RR 0.56, 95% CI 0.32 to 0.99). There was insufficient evidence to determine the effects of the two approaches on the failure of primary clearance of the bile duct (RR 0.55, 95% CI 0.22 to 1.38; participants = 517; trials = 5; I² = 58%; very low-quality evidence). The effects of either approach on clinical post-operative pancreatitis were unclear (RR 0.29, 95% CI 0.07 to 1.12; participants = 517, trials = 5; I² = 24%; low-quality evidence). Hospital stay appeared to be lower in the laparoscopic-endoscopic rendezvous group by about three days (95% CI 3.51 to 2.50 days shorter; 515 participants in five trials; low-quality evidence). There was very low-quality evidence that suggested longer operative time with laparoscopic-endoscopic rendezvous (MD 34.07 minutes, 95% CI 11.41 to 56.74; participants = 313; trials = 3; I² = 93%). The Trial Sequential Analyses of operating time and the length of hospital stay indicated that all the trials crossed the conventional boundaries, suggesting that the sample sizes were adequate, with a low risk of random error. There was insufficient evidence to determine the effects of the laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy techniques in people undergoing laparoscopic cholecystectomy on mortality and morbidity. The laparoscopic-endoscopic rendezvous procedure may lead to longer operating times, but it may reduce the length of the hospital stay when compared with preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy. However, no firm conclusions could be drawn because the quality of evidence was low or very low. If confirmed by future trials, these data might re-design the scenario of treatment of this condition, albeit requiring greater organisational effort. Future trials should also address issues such as quality of life and cost analysis.

Effect of laparoscopic choledocholithotomy with primary suture on stress response and gastrointestinal function in patients with common bile duct stones

Effect of laparoscopic choledocholithotomy with primary suture on stress response and gastrointestinal function in patients with common bile duct stones

Primary closure versus T-tube drainage after laparoscopic choledocholithotomy: a prospective randomized study

Background: Traditionally laparoscopic common bile duct exploration is followed by T-tube placement because of which patients suffer problems related to T-tube thereby increasing the morbidity of patients. Primary closure of CBD following laparoscopic choledocholithotomy is now being considered as an alternative superior to the traditional method. This study is designed to analyse the outcome of primary CBD repair in terms of mean operation time, duration of hospital stay and post-operative morbidity.Methods: A prospective randomized study was done in which 40 patients at our institute and associated hospitals were divided into two groups to compare the results of primary closure to T-tube placement following laparoscopic choledocholithotomy.Results: 40 patients were included in this study. The mean operating time was observed to be 65±14.05 mins in Group A (primary closure) patients while that in case of Group B (T-tube drainage) patients was 95.25±9.66 mins with a p-value 0.0001 which is considered statistically significant. The average duration of hospital stay in Group A (primary closure) was 8.2 days which was much shorter than that of Group B (T-tube drainage) patients which was of 15.7 days. The post-operative complication was observed in 1 patient of Group A (primary closure) while post-operative complication occurred in 3 patients of Group B (T-tube drainage).Conclusions: This study indicates that primary repair following laparoscopic choledocholithotomy is a safer and more effective method than T-tube drainage and we strongly recommend this procedure in clinical practice.

A Review of 7 Cases of Laparoscopic Cholecystectomy for Pediatric Cholecystolithiasis.

Pediatric cholecystolithiasis is a relatively rare disease, but it is recently increasing in Japan. Laparoscopic cholecystectomy (LC) is a standard procedure for cholecystolithiasis not only in adults but also in children, and we are aggressively introducing single-incision laparoscopic cholecystectomy (SILC) at our hospital. We reviewed the patient characteristics, operation procedures and outcomes of 7 children (15 years old and under) with cholecystolithiasis who underwent LC in our hospital between August 1995 and December 2015. The 7 patients included 5 males and 2 females, with a mean age of 8 years 6 months. Underlying diseases were found in 5 patients (cerebral palsy in 2 patients, pancreaticobiliary maljunction with common bile duct stones in 1, acute lymphocytic leukemia in 1, hereditary stomatocytosis in 1), and none were found in the other 2. LC (3 conventional LC and 2 SILC) was performed in 5 of the patients. Laparoscopic choledocholithotomy was performed in 1 patient and laparoscopic splenectomy (LS) was performed in 1 patient at the same time. The mean operative time in all the cases of LC was 108 (70-140) minutes (conventional LC 113 (70-140) min, SILC 100 (90-100) min). Intraoperative cholangiography was performed in 4 cases and omitted in 3 cases. The only postoperative complication was a wound infection in 1 patient. The umbilical skin incision length in the SILC was 2.0 cm. We conclude that LC can be safely performed for children with cholecsytolithiasis, and that SILC is feasible and advantageous in terms of its improved cosmesis.

Laparoscopic common bile duct exploration versus ERCP/stenting and cholecystectomy: Is a single staged procedure better?

Aims: Choledocholithiasis is most common cause of obstructive jaundice. Laparoscopic choledocholithotomy has evolved as an alternative procedure to ERCP/ stenting in the management of choledocholithiasis. This study was aimed to compare the outcomes of laparoscopic CBD exploration with cholecystectomy (group 1) as compared to the conventional two staged procedure involving ERCP/ stenting (group 2). Methods: 60 patients admitted to our department (mean age = 45.52, SD = 17.71, 15 males, 45 females) for the management of choledocholithiasis from April 2014 to October 2015 were included in the study. We reviewed retrospectively the patients' data including age, sex, duration of the surgery, intra-operative and postoperative complications, duration of hospital stay, mortality and condition on follow-up. Results: Group 1 included 30 patients (mean age 50.76, 21 females, 9 males). The average operative time in this group was 110 minutes (96–145), stone clearance rate was 100%, and average hospital stay was 3.2 days (2–9). Group 2 also included 30 patients (mean age 44.36, 24 females, 6 males) with stone clearance rate of 70% (21 out of 30), average operative time 120.7 minutes (90–167), average hospital stay 9.1 (3–30) days and an average of 2.3 procedures per patient. Conclusion: In our study mean operative time, stone clearance rate, average hospital stay and average number of procedures per patient were found to be significantly lower in laparoscopic CBD exploration group. It can be concluded that laparoscopic CBD exploration with cholecystectomy is much safer and cost effective than the conventional two staged procedure involving ERCP/ stenting.