Laparoscopic Transcystic Common Bile Duct Research Articles

Porcine Aorto-Renal Artery (PARA) model for laparoscopic transcystic common bile duct exploration: the evolution of a training model to meet new clinical needs

BackgroundThe transcystic approach to laparoscopic common bile duct exploration has gained popularity for the single-stage management of choledocholithiasis with concomitant gallstones. Our team previously described the use of a porcine aorta segment to simulate the common bile duct during laparoscopic skill training.MethodsWith the advent of the transcystic approach as a contender for the first-line technique of accessing the common bile duct, we present an evolution of the laparoscopic training model using a Porcine Aorta-Renal Artery (PARA) specimen to simulate the structural integrity, dimensions and spatial distribution of both the human cystic and common bile ducts.ResultsThis training model allows the use of a choledochoscope for transcystic exploration of the biliary tree. It combines fidelity and reproducibility required for a simulated training model to offer experience in laparoscopic transcystic common bile duct exploration. Validation of the model was demonstrated by 21 surgeons who completed a questionnaire after performing the simulated procedure. In all sections assessing reliability, face validity and content validity of the model, mean rating scores were between 4 and 5 out of five (good or excellent).ConclusionsWe present the evolution of an established training model for laparoscopic common bile duct exploration which focusses the attention on the transcystic approach to the common bile duct and the use of lithotripsy techniques. The need for such a model reflects the shift in the current practice of the laparoendoscopic management of choledocholithiasis with concomitant gallstones from transductal to transcystic approach.

Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass.

Treatment of choledocholithiasis after Roux-en-Y gastric bypass (RYGB) is a therapeutic challenge given the altered anatomy. To overcome this technical difficulty, different modified endoscopic approaches have been described but significant morbidity accompanies these procedures. The aim of the present study is to report our experience with laparoscopic transcystic common bile duct exploration (LTCBDE) as treatment of choledocholithiasis after RYGB. This is a retrospective cohort study of 854 consecutive patients with RYGB at a single institution between January 2007 and December 2019. Our study population focused on patients who developed biliary events after RYGB. Demographic data and perioperative parameters were compared between patients who underwent laparoscopic cholecystectomy (LC) after RYGB with (defined as Group A) and without (defined as Group B) LTCBDE. Fifty-seven (8.93%) patients developed a biliary event after RYGB that led to LC. Of those, 11 (19.2%) presented choledocholithiasis during intraoperative cholangiogram and were simultaneously treated with LTCBDE (Group A). Choledocholithiasis was unsuspected in the preoperative setting in 7 (63.6%) of the 11 patients. The procedure was successful in 90.9% (n = 10). Comparing Group A and B, no statistically significant differences were found regarding age, gender, length of hospital stay, and morbidity (p > 0.05). Mean operative time of Group A was 113.1min, adding, on average, 35min to LC (113.1min vs 77.9min, p = 0.004). LTCBDE offers an effective approach for common bile duct stones in patients who underwent RYGB. This procedure did not add significant length of hospital stay nor morbidity to laparoscopic cholecystectomy.

Long Term Outcomes of Trans-Cystic Bile Duct Exploration

Introduction: Laparoscopic transcystic common bile duct exploration (LTCBDE) at the time of cholecystectomy for choledocholithasis negates the need for endoscopic retrograde cholangiopancreatography (ERCP), along with its associated complications and cost. The aim of this study was to assess the long-term outcomes associated with TCBDE. Methods: Patients undergoing LTCBDE at the Royal Brisbane Hospital between 1995 and 2019 were retrospectively analysed. LTCBDE was performed using a 5.5-Fr wire basket kit (Cook Australia) under fluoroscopic guidance. Satisfactory completion of the CBD exploration was confirmed by completion cholangiography. Patients had clinical follow up post discharge. Data were analysed using R statistics with a p< 0.05 considered significant. Results: 397 patients underwent LTCBDE, with 262 females. The median age was 52 years old (range 16-88). Median follow up was 5.4 years, and the median length of hospital stay was 1 day (range 0 - 28). 28 patients (7.1%) required postoperative ERCP for failure of complete stone clearance at LTCBDE. Two patients developed mild acute pancreatitis postoperatively after successful duct clearance. Four patients (1%) required ERCP following discharge post LTCBDE, after representing with symptomatic choledocholithiasis. Overall, 91.9% of patients had successful bile duct clearance with LTCBDE. Cost analysis comparing LTCBDE with the average cost of patients undergoing ERCP followed by laparoscopic cholecystectomy showed LTCBDE to be significantly less (p< 0.05). Conclusion: Upfront laparoscopic CBDE is now a well-established practice at this unit. This study reports a high rate of bile duct stone clearance with LTCBDE, with minimal complications and obvious cost benefits.

The ABCdE score for PREdicting Lithotripsy Assistance during transcystic Bile duct Exploration by Laparoendoscopy (PRE-LABEL).

Common bile duct (CBD) stones are reported in ~ 15% of patients who undergo laparoscopic cholecystectomy for symptomatic gallstones. Prior to lithotripsy techniques, transcystic laparoscopic common bile duct exploration (LCBDE) was limited to smaller CBD stones. The addition of lithotripsy to LCBDE increases cost, operative time and staffing requirements. Predicting which patients might require lithotripsy would be useful in operative planning. The primary aim was to investigate clinical variables for predicting lithotripsy assistance during transcystic bile duct exploration by laparoendoscopy (PRE-LABEL). Secondary aims were to develop and validate a predictive scoring tool. A retrospective review of a prospectively collected database of consecutive patients who underwent transcystic LCBDE at a single centre in the UK was performed to investigate clinical variables for PRE-LABEL and develop a scoring tool (ABCdE score: age, bilirubin, CBD diameter, ERCP). Binary logistic regression was used to investigate which independent variables (predictors) were associated with lithotripsy assistance during transcystic LCBDE. The ABCdE score was applied to both UK and Spain patient cohorts to determine its sensitivity, specificity and accuracy. From 8 pre-operative clinical variables analysed, age ≤ 40years, bilirubin > two-times upper limit of normal, CBD diameter ≥ 10mm and ERCP failure of stone extraction were independent predictors of requiring lithotripsy during transcystic LCBDE and formed the ABCdE score. The hazard ratios were 2.87, 3.79, 2.78 and 10.06, respectively. An ABCdE score ≥ 2 resulted in 71% sensitivity, 81% specificity and 79% accuracy in predicting lithotripsy during LCBDE (UK cohort). Validation using a contemporary cohort from Spain yielded similar sensitivity, specificity and accuracy. This study represents the only study to date reporting independent predictors of requiring lithotripsy assistance during transcystic LCBDE. ABCdE score ≥ 2 can highlight patients that may require lithotripsy in order to avoid failure of transcystic LCBDE and therefore avoid choledochotomy or post-operative ERCP.

Laparoscopic transcystic common bile duct exploration (LTCBDE): a safer method to treat common bile duct stones than laparoscopic choledochotomy.

We read the article published in the Spanish Journal of Gastroenterology and its accompanying editorial about the laparoscopic treatment of both cholecystolithiasis and choledocholithiasis in a single stage procedure. We would like to make some comments. Common bile duct (CBD) stones can lead to serious complications such as cholangitis and pancreatitis. So far, there is no standard surgical treatment for choledocholithiasis. Although, there are some ways to deal with CBD stones. Each method has its own advantages and disadvantages. In the era of advancements in minimally invasive technology, the treatment of CBD stones still remains controversial with regard to endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). Preoperative ERCP followed by laparoscopic cholecystectomy (LC) is frequently performed.

Holmium laser lithotripsy improves the rate of successful transcystic laparoscopic common bile duct exploration

PurposeTranscystic laparoscopic common bile duct exploration (LCBDE) seems safer than transductal LCBDE and is associated with fewer biliary complications. It has traditionally been limited to smaller bile duct stones however. This study aimed to assess the ability of laser-assisted bile duct exploration by laparoendoscopy (LABEL) to increase the rate of successful transcystic LCBDE in patients with bile duct stones at the time of laparoscopic cholecystectomy.MethodsPatients undergoing LCBDE between 2014 and 2018 were retrospectively analysed. Baseline demographic and medical characteristics were recorded, as well as intra-operative findings and post-procedure outcomes. Standard LCBDE via the transcystic route was initially attempted in all patients, and LABEL was only utilised if there was failure to achieve transcystic duct clearance. The transductal route was utilised for failed transcystic extraction.ResultsOne hundred and seventy-nine consecutive patients underwent LCBDE; 119 (66.5%) underwent unaided transcystic extraction, 29 (16.2%) required LABEL to achieve transcystic extraction and 31 (17.3%) failed transcystic extraction (despite the use of LABEL in 7 of these cases) and hence required conversion to transductal LCBDE. As such, LABEL could be considered to increase the rate of successful transcystic extraction from 66.5% (119/179) to 82.7% (148/179). Patients requiring LABEL were however more likely to experience major complications (CD III–IV 5.6% vs 0.7%, p = 0.042) although none were specifically attributable to the laser intra-operatively.ConclusionsLABEL is an effective adjunct to LCBDE that improves the rate of successful transcystic extraction.

Protocol for the CREST Choles (Chinese REgistry Study on Treatment of Cholecysto-Choledocholithiasis) study: an ambispective, multicenter, observational, open-cohort study

IntroductionThe best approach for choledocholithiasis remains a matter of debate. Choledocholithiasis is usually treated with endoscopic sphincterotomy (EST), laparoscopic common bile duct exploration (LCBDE) or laparoscopic transcystic common bile duct...

Laparoscopic transcystic common bile duct exploration and laparoscopic transductal common bile duct exploration in elderly patients with cholecystolithiasis combined with choledocholithiasis.

Laparoscopic transcystic common bile duct exploration and laparoscopic transductal common bile duct exploration in elderly patients with cholecystolithiasis combined with choledocholithiasis.

Comparative Study between Laparoscopic Common Bile Duct Exploration and Endoscopic Retrograde Cholangiopancreatography Plus Laparoscopic Cholecystectomy for Choledocholithiasis

AbstractBackground: Overall, 5% to 15% of patients undergoing cholecystectomy for cholelithiasis have concomitant bile duct stones, and the incidence of choledocholithiasis increases with age. Endoscopic Retrograde Cholangiopancreatography (ERCP) with consequent Laparoscopic Cholecystectomy (LC) has been the favored approach for the treatment of choledo-cholithiasis for quite a long time; however in the course of recent years, Laparoscopic Common Bile Duct Exploration (LCBDE) has been offered to patients with suspected choledo-cholithiasis.Aim of Study: The aim of this work is to compare the efficacy, safety, and the surgical outcomes of LCBDE with ERCP followed by laparoscopic cholecystectomy and deter-mine the most appropriate approach for patients with choledo-cholithiasis.Patients and Methods: A prospective randomized clinical study was carried out from March 2017 to September 2018. It included 50 patients with cholecysto-choledocholithiasis who were divided into two groups: Group A (25 patients) included patients who underwent laparoscopic transcystic common bile duct exploration and stone extraction with LC in one stage, and Group B (25 patients) included patients who underwent endoscopic retrograde cholangiopancreatography for CBD stone extraction followed by LC in two stages. The Common Bile Duct (CBD) stone clearance rate, post-operative bile leakage, post-operative morbidity, mortality, overall hospital stay, and patient satisfaction were analyzed.Results: LCBDE and ERCP+LC were similar in terms of clearance rate, operative time postoperative complications, retained CBD stones, and postoperative length of stay, but there was a significant difference in number of procedures and patient satisfaction.Conclusion: Although both approaches have equivalent success rates, LCBDE is better in terms of fewer procedures, and better satisfaction compared with ERCP + LC. Our study suggests that one-stage management is the treatment of choice for patients with cholecystocholedocholithiasis.

Accuracy of magnetic resonance cholangiopancreatography for the diagnosis of choledocholithiasis in clinical practice

Introduction: To investigate the diagnostic efficacy of magnetic resonance cholangiopancreatography (MRCP) in choledocholithiasis and to determine whether use of MRCP may eliminate the need for purely diagnostic laparoscopic trans-cystic common bile duct (CBD) exploration (LTCBDE). Method: A total of 231 patients with suspected choledocholithiasis were studied retrospectively between January 2018 and December 2018. LTCBDE was used as the reference standard to assess the diagnostic yield of MRCP in detecting choledocholithiasis. When LTCBDE was unavailable, conversion to laparoscopic trans-duct exploration or conversion to open surgery was used as the reference procedure. Result: Forty-three patients were ineligible and excluded for failed common bile duct exploration (18, 7.8%) and lack of MRCP (25, 10.8%), leaving 188 patients for the analysis (175 undergoing LTCBDE, 8 converted to trans-duct exploration and 5 converted to open surgery). Ninety-six patients were diagnosed with choledocholithiasis by surgeries, and 65 by MRCP (k=0.48; P<0.001). The specificity and positive predictive value of MRCP were 90.2% and 86.2%, respectively. However, 40 of 123 patients (88 with a normal MRCP and 35 with CBD dilatation of more than 8mm) had choledocholithiasis identified by LTCBDE. The sensitivity and negative predictive value were 58.3% and 67.5%, respectively. The overall accuracy of MRCP in detecting choledocholithiasis was 73.9% and even decreased to 71.3% when incorporating the diameter of CBD (more than 8mm as a diagnostic criteria). Conclusion: MRCP seems to lack accuracy in diagnosing choledocholithiasis. Incorporation of the diameter of CBD did not improve performance. Purely diagnostic LTCBDE is still necessary in the management of suspected choledocholithiasis with negative findings on MRCP.

Laparoscopic Transcystic Common Bile Duct Exploration in the Emergency Is as Effective and Safe as in Elective Setting

BackgroundEmergent laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be on the increase in some institutions, reflecting the growing confidence with the technique. However, no study has focused on the outcomes of LTCBDE in the non-elective setting. The aim of this study is to investigate whether LTCBDE can be performed effectively and safely in the emergency. MethodsThis is a retrospective study of 500 consecutive patients with choledocholithiasis subjected for LTCBDE at the Hospital Italiano de Buenos Aires from January 2009 to January 2018. Procedures were classified according to the setting as emergent or elective. Demographic data and perioperative parameters were compared between groups. ResultsThroughout the period comprised, 500 patients were admitted for choledocholithiasis and gallstones. A single-step treatment combining LTCBDE and laparoscopic cholecystectomy was attempted: 211 (42.2%) were performed electively and the 289 (57.8%) as an emergency. There was no significant difference in the success rate of LTCBDE (93.9% versus 93.8%, p = 0.975) for the two groups. The operative time was slightly longer in the emergency group (122 ± 63 versus 106 ± 53 min, p = 0.002). Postoperative recovery was slower in the emergency group, as reflected by a higher rate of prolonged postoperative stay (21.1% vs 5.7%, p < .001). The rates of postoperative complications were similar between groups (2.8% vs 5.9%, p = 0.109). ConclusionEmergent LTCBDE can be performed with equivalent efficacy and morbidity when compared to an elective procedure. Patients undergoing emergent procedures have longer procedures and hospital stays.

Laparoscopic transcystic common bile duct exploration: surgical indications and procedure strategies

LTCBDE combined with or without modified techniques is safe and efficacious for the management of gallstones and concomitant, even large, common bile duct (CBD) stones. To describe the surgical indications and procedure strategies of laparoscopic transcystic common bile duct exploration (LTCBDE), a retrospective analysis of 205 patients with concomitant gallstones and CBD stones treated using LTCBDE between June 2008 and June 2015 was performed. Clinical data on disease characteristics, methods for cystic duct incision and CBD stone extraction (with or without laser lithotripsy), and surgical outcomes were collected and reviewed. CBD stones were successfully cleared in all patients. No patient was converted to choledochotomy or laparotomy. The cystic duct diameter ranged 3-8mm, and 85 patients with cystic duct diameter ≥ 5mm. The mean time for CBD stone extraction was 25.3min, with the operative time ranged from 63 to 170min. Lithotripsy was used in 74 (36.1%) patients among which 26 patients with cystic duct diameter ≥ 5mm. Estimated blood loss during surgery was 10-120ml per patient, and no intra-operative blood transfusions were needed. The mean postoperative hospital stay was 5.1 (range 3-7) days, and postoperative complications developed in seven patients. No bile duct injury, stricture, remnant, recurrent stones, or other adverse events were observed during the mean follow-up of 8 months. Based on preoperative MRCP and intra-operative IOC findings about cystic duct diameter, the diameter of CBD, CBD stone size, we summarized and proposed the surgical indications and suitable techniques and strategies during LTCBDE.

Predictors of Failed Transcystic Laparoscopic Common Bile Duct Exploration: Analysis of Multicenter Integrated Health System Database.

The aim of this study is to report our experience with laparoscopic common bile duct exploration (LCBDE) and validate the experts' opinion about anatomical predictors of failed transcystic LCBDE (TLCBDE) approach. Patients undergoing LCBDE at Kaiser Permanente Southern California hospitals (2005-2015) were included. Predictors of failed TLCBDE were identified using bivariate analysis. Of 115 LCBDE, 89.6% were TLCBDE and 10.4% through choledochotomy. Success rate, morbidity, and length of hospital stay were 83.5%, 6.1%, and 3.8 days respectively. Only stone size:cystic duct ratio >1 (35% versus 63%, P = .044) was associated with failure of TLCBDE. In accordance with experts' opinion, there was a suggestive association of stone size ≥6 mm, cystic duct ≤4 mm, multiple stones, and proximal stone location with failure; however, these did not reach statistical significance. LCBDE is an effective and safe mean of clearing common bile duct stones at community hospitals of an integrated health system. Previously cited contraindications for TLCBDE are not absolute, but rather predictors of failure.

Acute Pancreatitis After Laparoscopic Transcystic Common Bile Duct Exploration: An Analysis of Predisposing Factors in 447 Patients.

In laparoscopic transcystic common bile duct exploration (LTCBDE), the risk of acute pancreatitis (AP) is well recognized. The present study assesses the incidence, risk factors, and clinical impact of AP in patients with choledocholithiasis treated with LTCBDE. A retrospective database was completed including patients who underwent LTCBDE between 2007 and 2017. Univariate and multivariate analyses were performed by logistic regression. After exclusion criteria, 447 patients were identified. There were 70 patients (15.7%) who showed post-procedure hyperamylasemia, including 20 patients (4.5%) who developed post-LTCBDE AP. Of these, 19 were edematous and one was a necrotizing pancreatitis. Patients with post-LTCBDE AP were statistically more likely to have leukocytosis (p < 0.004) and jaundice (p = 0.019) before surgery and longer operative times (OT, p < 0.001); they were less likely to have incidental intraoperative diagnosis (p = 0.031) or to have biliary colic as the reason for surgery (p = 0.031). In the final multivariate model, leukocytosis (p = 0.013) and OT (p < 0.001) remained significant predictors for AP. Mean postoperative hospital stay (HS) was significantly longer in AP group (p < 0.001). The risk of AP is moderate and should be considered in patients with preoperative leukocytosis and jaundice and exposed to longer OT. AP has a strong impact on postoperative HS.

Laparoscopic ultrasonography in surgical treatment of secondary choledocholithiasis

Objective To investigate the diagnostic accuracies among laparoscopic ultrasonography (LUS), CT, MRCP and transabdominal ultrasonography in secondary choledocholithiasis, and to compare the procedural efficacy of LUS carried out by surgeons assisted by ultrasound physicians, and by surgeons alone. Methods Forty-two patients underwent laparoscopic transcystic common bile duct exploration (LTCBDE) in Beijing Luhe Hospital, Capital Medical University. All these patients underwent LUS examination. In 26 patients, LUS was carried out by surgeons alone while in 16 patients it was assisted by ultrasound physicians. The results of intraoperative choledochoscopy were used to verify the results in the two groups in scan time, and in its accuracies when compared with CT, MRCP and preoperative abdominal ultrasound. Results The accuracy of LUS was 92.9%, which was significantly better than that of CT (73.8%) and transabdominal ultrasonography (23.8%, P 0.05). Surgeons alone were faster than ultrasound physicians in performing LUS [(8.5±3.0) min vs (13.2±4.6) min, P 0.05). Conclusion LUS diagnosed common bile duct stones by surgeons who had adequate ultrasound training, with a high accuracy rate and good efficiency. Key words: Laparoscopic ultrasound; Secondary choledocholithiasis; Bile duct exploration

Acute pancreatitis after laparoscopic trans-cystic common bile duct exploration (LTCBDE): An analysis in 447 consecutive patients

Acute pancreatitis after laparoscopic trans-cystic common bile duct exploration (LTCBDE): An analysis in 447 consecutive patients

Strategies of minimally invasive treatment for intrahepatic and extrahepatic bile duct stones.

Cholelithiasis is a kind of common and multiple diseases. In recent years, traditional laparotomy has been challenged by a minimally invasive surgery. Through literature review, the therapeutic method, effect, and complications of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones by combining our practical experience were summarized as follows. (1) For intrahepatic bile duct stones, the operation may be selected by laparoscopic liver resection, laparoscopic common bile duct exploration (LCBDE), or percutaneous transhepatic cholangioscopy. (2) For concomitant gallstones and common bile duct stones, the surgical approach can be selected as follows: laparoscopic cholecystectomy (LC) combined with endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation, LC plus laparoscopic transcystic common bile duct exploration, LC plus LCBDE, and T-tube drainage or primary suture. (3) For concomitant intrahepatic and extrahepatic bile duct stones, laparoscopic liver resection, choledochoscopy through the hepatic duct orifice on the hepatectomy cross section, LCBDE, EST, and percutaneous transhepatic cholangioscopic lithotripsy could be used. According to the abovementioned principle, the minimally invasive treatment approach combined with the surgical technique and equipment condition will be significant in improving the therapeutic effect and avoiding the postoperative complications or hidden dangers of intrahepatic and extrahepatic bile duct stones.

A novel laparoscopic transcystic approach using an ultrathin choledochoscope and holmium laser lithotripsy in the management of cholecystocholedocholithiasis: An appraisal of their safety and efficacy

BackgroundAlthough laparoscopic transcystic common bile duct exploration (LTCBDE) is the preferred approach for CBD stone clearance, the success rate can vary between 55% and 85%. This study evaluated if ultrathin choledochoscope and holmium laser lithotripsy could improve the success rate of LTCBDE. MethodsRecords of 126 patients (average age, 46.1 ± 13.8 years) with cholecystocholedocholithiasis treated with laparoscopic cholecystectomy (LC) and LTCBDE were retrospectively reviewed. ResultsLC+LTCBDE was performed successfully in 118 of 126 patients, with a surgical success rate of 93.7%. An ultrathin choledochoscope was used in 75 (63.5%) patients, and holmium lithotripsy was performed in 38 (32.2%) patients. The stone clearance rate was 99.2% (117/118). No significant complications occurred. One hundred (84.7%) patients had excellent and 13 (11%) had good outcomes for an overall success rate (excellent plus good) of 95.7%. ConclusionUltrathin choledochoscope and holmium laser lithotripsy can improve the surgical outcomes of LC+LTCBDE with minimal complications.

Gangrenous cholecystitis: innovative laparoscopic techniques to facilitate subtotal fenestrating cholecystectomy when a critical view of safety cannot be achieved.

Gangrenous cholecystitis is associated with a higher conversion rate of conversion from laparoscopic to open than acute non-gangrenous cholecystitis. New strategies and techniques are needed to decrease conversion rates and improve outcomes. In this article, we provide a richly detailed, illustrated description of a modified fundus-first technique that we have developed over the last 15years and now use routinely with rare conversions. We also compared outcomes of laparoscopic (LC) and open (OC) approaches for pathologically confirmed gangrenous cholecystitis in 146 patients during 1995-2005, the first 10years during which these two approaches were performed contemporaneously at our institution on comparable patients. Among the 142 patients that met the inclusion criteria, laparoscopic procedures were started in 112 (79%) of these patients, with successful completion in 72 resulting in an overall conversion rate of 36%. During the last 5years, however, in cases where the described laparoscopic technique was used, no patient has required conversion. The laparoscopic LC group had shorter average ICU stay (p<0.05) and overall length of stay (2 vs 6days, p<0.001). Intraoperative cholangiography was completed in 37 of 72 LC patients (52%) versus 6 of 30 OC (20%). In five of the LC patients, a filling defect was seen on the cholangiogram and laparoscopic transcystic common bile duct stones, thereby avoiding a second anesthetic and endoscopic procedure. In the setting of severe inflammation, a number of procedural modifications can be incorporated to allow the surgeon to approach dissection of the gangrenous gallbladder using a flexible operative plan designed to optimize safe completion of this challenging procedure, with the expected improvement in surgical outcomes.

What Should We Do for the Failed Laparoscopic Transcystic Common Bile Duct Exploration

What Should We Do for the Failed Laparoscopic Transcystic Common Bile Duct Exploration