Bile Duct Lesions Research Articles

Brachytherapy in the treatment of bile duct cancer - a tough challenge.

The majority of patients with bile duct cancer are diagnosed with clinically advanced disease. Most of these patients have a short life expectancy and are treated with palliative aim. Most patients present with locally advanced or metastatic disease, which is not amenable to surgical resection, resulting in poor survival. Adjuvant or definitive radiotherapy, with or without chemotherapy, is therefore used in many centers worldwide for better local control, and with the expectation that it will have a favorable effect on survival. However, the lack of appropriate prospective trials, as well as the small size of the published series and their retrospective nature, has produced insufficient evidence for the best treatment for these patients. Intraluminal brachytherapy is an important component in the multimodality approach to bile duct cancers. The objective of this treatment is to deliver a high local dose of radiation to the tumor while sparing surrounding healthy tissues. The treatment can be safely adapted for right and left hepatic duct, and for common bile duct lesions. Brachytherapy plays a limited but specific role in definitive treatment with curative intent in selected cases of early disease, as well as in the postoperative treatment of small residual disease. Depending on the location of the lesion, in some cases, brachytherapy is a treatment of choice. Clinical indications, different techniques, results, and complications are discussed in this work.

Positive antimitochondrial antibody but normal serum alkaline phosphatase levels: Could it be primary biliary cholangitis?

Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease, typically diagnosed by elevated cholestatic liver enzymes and a positive antimitochondrial antibody (AMA) test. The clinical significance of AMA positivity in patients with normal cholestatic liver enzymes is uncertain. Charts of patients with normal cholestatic liver enzymes and AMA positivity who underwent liver biopsy between 2012 and 2015 were retrospectively analyzed. Six AMA-positive patients with normal cholestatic liver enzymes who underwent a liver biopsy were identified. Four (67%) showed florid bile duct lesion compatible with early-stage PBC, whereas the other two showed mild and non-specific histological findings. The patients with histological findings compatible with PBC had higher enzyme-linked immunosorbent assay-determined AMA titers and significantly elevated immunoglobulin M (IgM) level. Patients with non-specific histological findings (33%) had low-titer AMA and a borderline elevated IgM level. Antimitochondrial antibody-positive patients with normal cholestatic liver enzymes should be meticulously evaluated for PBC including a liver biopsy, mainly in patients with high-titer seropositivity for AMA and a significantly elevated IgM level. More studies are required to clarify the role of liver biopsy in these patients and further follow-up may elucidate the relationship of these patients to those with more classical forms of PBC.

Liver Microabscesses Due to Choledocholithiasis Masquerading as Metastatic Liver Lesions

A 56 year-old man with a past medical history of HTN presented with 2.5 weeks of right upper quadrant abdominal pian and a 20lb weight loss. Reported fevers, chills, jaundice, and tea colored urine. Laboratory findings were significant for an elevated total bilirubin of 2.1 mg/dl and an alkaline phosphatase of 918 IU/L. A CT scan of the abdomen and pelvis with IV contrast showed multiple irregularly shaped hypoattenuating masses disseminated throughout the liver with the largest measuring 3.1 cm and a lamellated soft tissue mass within the common bile duct extending into the right and left intrahepatic bile ducts. A subsequent MRI showed several filling defects throughout the biliary tract with ductal dilation. An ERCP was performed which revealed large grape like gallstones filling the common bile duct. While performing cholangioscopy, the stones were fragmented using the holmium laser and removed with balloon sweeps. Brushings of the biliary tree did not reveal any evidence of malignancy. The patient was discharged on intravenous antibiotics. On subsequent follow up, the patient was asymptomatic and his liver was normal appearing on MRI, with no evidence of biliary obstruction, choledocholithiasis, or malignancy. There are 3 major etiologies for a liver abscess: pyogenic (80%), amebic (10%) and fungal (< 10%). A pyogenic liver abscess usually arises from the biliary tract due to the obstruction of bile flow. Typically, a patient will present with continuous or intermittent fever, right upper quadrant pain, weight loss, nausea and vomiting. Jaundice may be present in 25% of patients associated with biliary tract disease. A CT Scan with IV contrast remains the diagnostic modality of choice and can be used for guiding percutaneous aspiration and drainage, when needed. In this case, the patient presented with chronic intermittent fever, right upper quadrant pain, weight loss with no elevation in his white blood count. The CT scan finding of a lamellated mass in the common bile duct and multiple hypoattenuation liver lesions, gave the appearance of an intraductal cholangiocarcinoma, rather than choledocholithiasis which is a rare presentation of liver abscess masquerading malignancy. Because the liver abscesses were caused by the obstruction of bile flow from choledocholithiasis, the patient was treated with broad spectrum antibiotics and ERCP with cholangioscopy, lithotripsy, and stone extraction rather than percutaneous drainage of the liver abscesses.Figure 1Figure 2Figure 2

Histopathology of a benign bile duct lesion in the liver: Morphologic mimicker or precursor of intrahepatic cholangiocarcinoma.

A bile duct lesion originating from intrahepatic bile ducts is generally regarded as an incidental pathologic finding in liver specimens. However, a recent study on the molecular classification of intrahepatic cholangiocarcinoma has focused on the heterogeneity of this carcinoma and has suggested that the cells of different origins present in the biliary tree may have a major role in the mechanism of oncogenesis. In this review, benign intrahepatic bile duct lesions—regarded in the past as reactive changes or remnant developmental anomalies and now noted to have potential for developing precursor lesions of intrahepatic cholangiocarcinoma—are discussed by focusing on the histopathologic features and its implications in clinical practice.

Gallengangsrekonstruktion mittels Umbilikalvene nach laparoskopischer Cholezystektomie

Background: Roux-Y hepaticojejunostomy is currently the standard surgical procedure for the reconstruction of the bile duct after iatrogenic transection in laparoscopic cholecystectomy. However, about 30 % of all hepaticojejunostomies develop a stenosis after some time and in 7 % a cholangiocellular carcinoma occurs. Therefore, alternative procedures have been investigated. Patients: Between September 2009 and October 2013 an iatrogenic bile duct lesion was treated in 6 consecutive patients by using the pedicled umbilical vein. The median follow-up period was 16 months. Methods: In 3 cases, the bile duct lesion was detected during cholecystectomy and reconstructed in the same session. In the other 3 cases, the reconstruction was performed between the fourth and the seventh day after cholecystectomy. The pedicled umbilical vein was used as a patch in 4 cases and as an interposition graft in the other 2 cases. Results: Two out of 6 patients suffered from cholangitis after bile duct reconstruction, which was brought to complete remission by temporary endoscopic dilatation treatment. Conclusion: The use of the pedicled umbilical vein is a new surgical option for the treatment of iatrogenic bile duct lesions and seems to provide advantages over hepaticojejunostomy regarding the development and treatment of anastomotic stenosis and the risk of cholangiocellular carcinoma.

Detection of benign hilar bile duct stenoses - A retrospective analysis in 250 patients with suspicion of Klatskin tumour

IntroductionThe aim of this study was to identify clinical, laboratory and radiological parameters to distinguish benign from malignant stenoses of the proximal bile duct.MethodsBetween 1997 and 2011, 250 patients were referred to our clinic with hilar bile duct stenoses suspicious for Klatskin tumour. Medical histories, clinical data, pre-interventional laboratory tests, imaging findings, as well as therapeutic approach and patient outcome were compared to final histological results. All data were retrieved from our prospectively maintained database and analysed retrospectively.ResultsWe found benign bile duct lesions in 34 patients (13.6%). Among the entire study population, uni- and multivariate analyses of 18 clinicopathological parameters revealed that patient age, serum alkaline phosphatase, tumour marker CA19-9 and presence of tumour mass in computed tomography were independent predictors for malignant biliary stenoses (p < 0.05). Receiver operator characteristic curve showed that a CA19-9 serum level of 61.2 U/ml or more has a sensitivity, specificity and diagnostic accuracy for predicting the malignant nature of the hilar biliary stenoses of 74.6%, 80.0% and 83.5%, respectively. Surgical resection could be avoided by preoperative work-up and surgical exploration in 10 out of 34 patients with benign lesions. Rates of major liver resections performed were 66.7% in the benign lesion group and 90.7% in the Klatskin tumour group.ConclusionDespite improvements of preoperative diagnostics, it remains difficult to differentiate between benign and malignant hilar bile duct stenosis. Even explorative laparotomy was not able to safely exclude Klatskin tumour in all cases and therefore major liver resection was inevitable.

Biliary tract injuries after lap cholecystectomy-types, surgical intervention and timing.

Bile duct lesions, including leaks and strictures, are immanent complications of open or laparoscopic cholecystectomy (LC). Endoscopic procedures have gained increasing potential as the treatment of choice in the management of postoperative bile duct injuries. Bile duct injury (BDI) is a severe and potentially life-threatening complication of LC. Several series have described a 0.5% to 0.6% incidence of BDI during LC. Early recognition and an adequate multidisciplinary approach are the cornerstones for the optimal final outcome. Suboptimal management of injuries often leads to more extensive damage to the biliary tree and its vasculature. Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results.

New digital cholangiopancreatoscopy for diagnosis and therapy of pancreaticobiliary diseases (with videos).

Recently, a new digital cholangiopancreatoscopy (DCPS) has been developed. The aim of this study is to retrospectively evaluate the utility of new DCPS in patients with pancreaticobiliary diseases. Digital cholangiopancreatoscopy was used in 26 patients (16 men) with pancreaticobiliary diseases that could not be diagnosed and treated by standard endoscopic retrograde cholangiopancreatography (ERCP). The procedures included DCPS-guided tissue sampling and interventions. Technical success and adverse events were evaluated. Among the 26 patients, 19 patients were classified for diagnostic purposes and seven for therapeutic purposes. The detailed breakdown of the particular conditions and numbers of patients was as follows: indeterminate bile duct (BD) lesion, indeterminate pancreatic duct (PD) lesion, lithotripsy by yttrium aluminum garnet-laser or electrohydraulic lithotripsy, removal of migrated BD stent and PD stent, and guidewire passing across the biliary stricture. The overall technical success rates of visualizing the target lesions and therapeutic interventions were 100% and 85.7%, respectively. The incidence of procedure-related adverse events among the patients was 7.7% (2/26). Cholangitis developed in one of the patients and post-endoscopic sphincterotomy bleeding in one patient. All adverse events were successfully treated by conservative therapy. Digital cholangiopancreatoscopy has a high potential for providing an accurate diagnosis and facilitating therapy in patients with pancreaticobiliary diseases.

Novel immunohistochemical markers differentiate intrahepatic cholangiocarcinoma from benign bile duct lesions

AimsThe distinction between intrahepatic cholangiocarcinoma (ICC) and benign bile duct lesions can be challenging. Using our previously identified potential biomarkers for ICC, we examined whether these are useful for the...

The efficacy of endoscopic endosonography in diagnosis of benign and malignant stenoses of common bile duct

To define criteria and to estimate diagnostic significance of endosonography in differential diagnosis of benign and malignant stenoses of common bile duct. We presented the results of survey and treatment of 57 patients with benign and malignant stenoses of common bile duct. The technique of endosonography is described. We have formulated major criteria of differential diagnostics of tumoral and non-tumoral lesion of extrahepatic bile ducts. Comparative analysis of endosonography, ultrasound, computed tomography and magnetic resonance cholangiopancreatography was performed. Sensitivity, specificity and accuracy of endosonography in diagnosis of stenosis cause is 97.7%, 100% and 98.2% respectively. So it exceeds the efficacy of other diagnostic X-ray methods. In modern surgical clinic endosonography should be mandatory performed. It is necessary for final diagnostics of cause of common bile duct stenosis especially in case of its low location.

Value of iterative reconstruction technique combined with biliary reconstruction in diagnosis of common bile duct lesions

Value of iterative reconstruction technique combined with biliary reconstruction in diagnosis of common bile duct lesions

Biliary tree stem cells are involved in the pathogenesis of primary sclerosing cholangitis

Biliary tree stem cells (BTSCs) are multipotent stem cells located in peribiliary glands (PBGs) of extrahepatic and large intrahepatic bile ducts (1). Primary sclerosing cholangitis (PSC) is characterised by fibro-stenosing strictures involving extrahepatic and/or large intrahepatic bile ducts. Mechanisms leading to bile duct injury are poorly understood (2). Our aims are to study the role of BTSC in the pathogenesis of biliary fibrosis in PSC. Specimens containing extrahepatic or large intrahepatic bile ducts were obtained from normal liver (n=6), liver explants from patients with PSC (n=11), and primary biliary cirrhosis (n=6). Specimens were processed for histology, immunohistochemistry and immunofluorescence. In PSC samples, progressive hyperplasia and mucinous metaplasia of PBGs were observed in large ducts with fibrosis, but not in inflamed ducts without fibrosis. PBG hyperplasia was associated with progressive biliary fibrosis and the occurrence of dysplastic lesions. Hyperplasia of PBGs was determined by the expansion of biliary tree stem cells, which sprouted towards the surface epithelium. In PSC, PBGs and myofibroblasts displayed enhanced expression of Hedgehog pathway components. PBGs in ducts with onion skin-like fibrosis expressed epithelial-to-mesenchymal transition traits associated with components of Hedgehog pathway, markers of senescence and autophagy. The biliary tree stem cell compartment is activated in PSC, its activation contributes to biliary fibrosis, and is sustained by the Hedgehog pathway. Our findings suggest a key role for peribiliary glands in the progression of bile duct lesions in PSC and could explain the associated high risk of cholangiocarcinoma. This work was supported by grants from MIUR FIRB 2010 and MIUR PRIN-2009.

Diagnostic and therapeutic single-operator cholangiopancreatoscopy in biliopancreatic diseases: Prospective multicenter study in Japan.

To assess the utility and safety of single-operator cholangiopancreatoscopy (SOCPS) using the SpyGlass system in widespread clinical application for biliary and pancreatic diseases. This study was a prospective case series conducted in 20 referral centers in Japan. There were 148 patients who underwent SOCPS; 124 for biliary diseases and 24 for pancreatic diseases. The attempted interventions were SOCPS examination, SOCPS-directed tissue sampling, and therapy for stone removal, among others. The main outcomes were related to the procedure success rate in terms of visualizing the target lesions, SOCPS-directed adequate tissue sampling, and complete stone removal. A total of 148 patients were enrolled for the diagnosis of indeterminate biliary and pancreatic lesions or treatment of biliary and pancreatic disease. The overall procedure success rate of visualizing the target lesions was 91.2% (135/148). The overall procedural success rates of visualizing the target lesions of diagnostic SOCPS in the bile duct and pancreatic duct were 95.5% (84/89) and 88.2% (15/17), respectively. the overall adequate tissue for histologic examination was secured in 81.4% of the 86 patients who underwent biopsy under SOCPS (bile duct, 60/75, 80.0%; pancreatic duct, 10/11, 90.9%). The accuracy of histologic diagnosis using SOCPS-directed biopsies in indeterminate bile duct lesions was 70.7% (53/75). In the pancreatic duct, the accuracy of SOCPS visual impression of intraductal papillary mucinous neoplasm was 87.5% (14/16). Stone therapy: complete biliary and pancreatic stone clearance combined with SOCPS-directed stone therapy using electrohydraulic lithotripsy or laser lithotripsy was achieved in 74.2% (23/31) and 42.9% (3/7) of the patients, respectively. Others: SOCPS using the SpyGlass system was used in cannulation of the cystic duct in two patients and for passing across the obstructed self-expandable metallic stent for a malignant biliary stricture in two patients. All procedures were successful in both SOCPS-guided therapies. The incidence of procedure-related adverse events was 5.4% (8/148). SOCPS with direct visualization and biopsy for diagnosis and SOCPS-directed therapy for biliary and pancreatic diseases can be safely performed with a high success rate. The clinical trial was registered at UMIN CTR (http://www.umin.ac.jp). The registration identification number is UMIN000015155.

Pathological spectrum of bile duct lesions from chronic bile duct injury to invasive cholangiocarcinoma corresponding to bile duct imaging findings of occupational cholangiocarcinoma.

We aimed to identify the pathological characteristics of occupational cholangiocarcinoma. We examined the location and distribution of the carcinomas: atypical epithelium including biliary intraepithelial neoplasia (BilIN) and intraductal papillary neoplasm of the bile duct (IPNB); and chronic bile duct injuries in operative or autopsy liver specimens from 16 patients. We examined the detailed pathological findings and diagnostic imaging of three patients. Immunohistochemical analysis using primary antibodies against γH2AX and S100P was performed. BilIN and chronic bile duct injury were observed in 16 patients, and IPNB or invasive IPNB was observed in 11 patients. BilIN, IPNB, and/or chronic bile duct injury were observed in almost all the large bile ducts. Regional dilatation of the bile ducts without tumor-induced obstruction revealed such pathological changes. Highly positive results for the γH2AX and S100P markers were noted in invasive carcinoma, BilIN, and IPNB, whereas positive results for γH2AX and negative results for S100P were noted in non-neoplastic biliary epithelium. The carcinogenic process of occupational cholangiocarcinoma comprised chronic bile duct injury and DNA damage in almost all the large bile ducts, along with induction of precancerous lesions and development of invasive carcinoma. Such pathological findings reflected radiological changes on diagnostic imaging.

A case of polypoid lesions of the common bile duct observed on peroral video cholangioscopy

A 75-year-old male was admitted to our hospital with epigastric ain and serum liver enzyme abnormalities. Contrast-enhanced CT howed irregular thickening of the wall of the middle bile duct. RCP disclosed wall irregularities in the middle bile duct with a ranular filling defect, and peroral video cholangioscopy (PVCS) emonstrated many polypoid lesions extending from the bifurcaion of the cystic duct branch to the distal bile duct (Fig. 1 white ight (a), NBI (b)). A forceps biopsy of the lesions showed lymphoid ollicles without any evidence of malignancy histopathologically. owever, the patient underwent pancreaticoduodenectomy with xtrahepatic bile duct resection under suspicion of cholangiocarcioma.

Integrated analysis of autoimmune pancreatitis by CT, MRCP and DWI

PurposeCT, MRCP and diffusion weighted imaging characteristics were discussed to improve the diagnostic accuracy of autoimmune pancreatitis. Materials and methods23 cases of confirmed autoimmune pancreatitis were retrospectively analyzed before treatments. 23 cases underwent CT unenhanced and enhanced scans, 21 cases underwent MRCP examination, and 11 cases underwent DWI examination. Pancreatic lesion, involvement of the pancreatic duct and bile duct, changes of adjacent artery and vein, and other organs lesions. CT values and ADC values of pancreas and lesion were measured. ResultsFocal type lesions were shown in 6 cases, diffuse type in14 cases, and both types in 3 cases. Diffuse pancreatic swelling was shown in 20 cases, and peripancreatic halo in 13 cases. Mean CT values of lesions: unenhanced scan 35.81 ± 6.23 HU, late arterial phase 75.80 ± 17.47 HU, venous phase 93.19 ± 14.06 HU, and equilibrium phase 90.00 ± 14.67HU. Delayed homogenous enhancement was shown in 17 cases. Tapered narrowing (12 cases) or multiple segmental pancreatic duct stenosis (8 cases) was detected, the absence of main pancreatic duct dilatation or less than 3.5 mm in 20 cases, and duct penetrating sign in 20 cases. Bile duct lesions were found in 20 cases. ADC values of lesions (0.99 ± 0.03 × 103 mm2/s) were significantly lower that of pancreas (1.47 ± 0.16 × 103 mm2/s). ConclusionCT and MRI integrated diagnosis was helpful for accurate diagnosis based on the distinctive imaging characteristics of autoimmune pancreatitis.

Adenomas involving the extrahepatic biliary tree are rare but have an aggressive clinical course.

Biliary adenomas that are usually found in surgically removed gallbladders are rare, but can also occur in the extrahepatic biliary tree. We present a case series of extrahepatic bile duct adenomas at our institution, along with a review of the literature. All three patients with extrahepatic biliary adenomas (two in the common bile ducts, one in the hepatic duct) were female with a mean age of 74 years. On initial presentation, none of the patients had obstructive jaundice but two of the three patients had symptoms of biliary origin. Case 1 is an 85-year-old woman with an incidental biliary dilation seen on chest imaging; endoscopic ultrasound revealed a sessile adenomatous polyp in the distal bile duct. The patient refused surgery and presented with occlusive biliary stricture and jaundice 5 months after initial presentation, with cytology confirming malignant progression. Case 2 is a 78-year-old woman with a history of primary sclerosing cholangitis and who presented with cholangitis, and Gram-negative sepsis. A polypoid lesion was seen on imaging in the common hepatic duct and direct cholangioscopy with biopsies confirmed the presence of adenoma with high grade dysplasia. The patient underwent successful total bile duct resection and hepaticojejunostomy but represented 1 year later with diffuse metastatic disease to the bone, liver, and peritoneum. Case 3 is a 61-year-old woman who presented with symptoms suggestive of gallbladder pathology and was found to have a polypoid bile duct lesion on intraoperative cholangiogram. Endoscopic retrograde cholangioscopy showed an adenomatous polyp with high grade dysplasia involving the distal common bile duct. The patient underwent distal bile duct resection with choledochojejunostomy but presented with jaundice 4 years after surgery. She was found to have adenocarcinoma involving the small bowel in the Roux limb of jejunum and transverse colon. All three patients in our series presented with interval gastrointestinal malignancy and we therefore recommend aggressive surgical intervention and close postoperative surveillance when diagnosis of extrahepatic bile duct adenoma is made.

A Case of Direct Peroral Cholangioscopy-Guided Intraductal Radiofrequency Ablation for Malignancy Biliary Obstruction via Choledochoduodenostomy Orifice

ìˆ˜ìˆ ì´ 불가능한 담관암에서 담관 내 ê³ ì£¼íŒŒ 열치료는 ì• ì„± 담관 폐쇄를 í˜¸ì „ì‹œí‚¤ëŠ” ì‹¤ìš©ì ì¸ 치료로 ë³´ê³ ë˜ê³ ìžˆìœ¼ë‚˜, ë‚´ì‹œê²½ì  역행성 ë‹´ì·Œê´€ì¡°ì˜ìˆ ì„ 이용한 ê³ ì£¼íŒŒ 열치료는 투시조영을 통해 열을 ì ìš©í•˜ëŠ” 방법으로, 병변을 ì§ì ‘ 시각화하지 못하는 ë‹¨ì ì´ 있다. 반면에, ì§ì ‘ 경구 담관 내시경하 담관 내 ê³ ì£¼íŒŒ 열치료는 담관 내 병변을 시각화함으로써 ì¹´í Œí„°ì˜ ì‚½ìž ë“±ì— 용이하며 ì‹œìˆ ë¡œ 인한 합병증을 감소시킬 수 있을 것으로 ê¸°ëŒ€ë˜ê³ ìžˆë‹¤. 본 증례에서는 ì´ë‹´ê´€ì‹­ì´ì§€ìž¥ë¬¸í•©ìˆ ì„ 시행 받은 담관암 환자에서 ì§ì ‘ 경구담관 내시경하 담관 내 ê³ ì£¼íŒŒ 열치료를 ì ìš©í•˜ì—¬ì„œ ìŠ¤í íŠ¸ ì‹œìˆ ì—†ì´ 담관 개존을 보존한 첫 번째 사례로서 ì§ì ‘ 경구담관 내시경하 담관 내 ê³ ì£¼íŒŒ 열치료의 효용성을 문헌 ê³ ì°°ê³¼ 함께 ë³´ê³ í•˜ëŠ” 바이다. Keywords: 담관암, 담관 내 ê³ ì£¼íŒŒ 열치료, ì§ì ‘ 경구 담관 내시경

La cholangite à lésion épithéliale granulocytique : une nouvelle entité avec un traitement spécifique

Herein, we report a case of cholangitis with granulocytic epithelial lesion associated with pancreatitis in a 22-year-old patient. The association of bile duct lesions and pancreatitis is usually very suggestive of IgG4related disease. However, in our case, we found no IgG4tissue infiltration and we found a granulocytic epithelial on the liver biopsy. Recently, cholangitis with granulocytic epithelial lesion was described in the literature. This entity is identified in 2% of patients with sclerosing cholangitis. Patients are more likely children or young adults and often have an associated inflammatory bowel disease or rarely a pancreatitis. It is defined by the presence of neutrophilic bile duct lesions on a liver biopsy. Although rare, the diagnosis of cholangitis with granulocytic epithelial lesion is important because of its excellent response to immunosuppressive treatment.

Minilaparoscopic cholecystectomy - the new non-visible scars technique. Preliminary report of first series.

IntroductionSurgery without scars is the dream of many patients and surgeons as well. It includes many new laparoscopic techniques (LESS, SILS, hybrid NOTES), but data concerning common bile duct (CBD) lesions are unavailable.AimTo establish the new technique of minilaparoscopic cholecystectomy (MCh): non-visible scar intervention without increasing the risk of CBD lesions.Material and methodsForty consecutive patients with symptomatic gallbladder lithiasis were qualified for elective laparoscopic cholecystectomy (LCh) using one 10/11 mm umbilical port, one 5 mm right suprapubic port and two minilaparoscopic, disposable, no-port graspers. There were 26 women and 14 men, with the mean age 56 (17–72) years and with the average body mass index 28 (18–33) kg/m2. CO2 Veress 15 mm Hg pneumoperitoneum was performed after transumbilical incision, and the first 10/11 mm port was inserted at the beginning for the 5 mm laparoscope and finally for typical instruments. Next under camera control, a 5 mm trocar was inserted in the right ‘bikini line’. To this port the laparoscope was relocated from the umbilicus, and under its control two minilaparoscopic, disposable, non-port graspers were introduced after small, 2 mm skin incisions in the right anterior axillary line and in the right mesogastrium to catch the gallbladder. Next through the umbilical port, using typical instruments, the cystic duct and artery were dissected, clipped and cut. The gallbladder was removed through the umbilical port whole.ResultsThere was no conversion to open cholecystectomy. In 5 cases drainage of the gallbladder lodge was necessary through a 5 mm port in the right bikini line. The time of the intervention ranged from 90 min during the introduction of the new method to 50 min for the last procedures. No postoperative complications were observed, and all patients were discharged at the same time as after conventional LCh.ConclusionsTwo-port laparoscopic cholecystectomy performed with two minilaparoscopic no-port graspers does not increase the risk of CBD lesions. It provides an excellent cosmetic effect and is very convenient for the surgeon like typical LCh.