The role of choledochoscopy in transductal laparoscopic common bile duct exploration

Laparoscopic common bile duct exploration (LCBDE) performed by choledochoscope through the cystic duct or directly through the incision in the common bile duct (CBD) are well established methods for restoring biliary drainage function in patients with choledocholithiasis. Although it plays a crucial role in the transcystic approach, transductal approach can be achieved differently. However, it has restrictions in availability due to its expensiveness. Objective — to report efficacy of transductal LCBDE without laparoscopic choledochoscopy. Materials and methods. This is a prospective study of urgently admitted patients who underwent trans‑ductal LCBDE due to confirmed choledocholithiasis. During laparoscopy, clearance of the CBD was achieved in two ways: by choledochoscopy (group CS+, n = 43) and without it (group CS–, n = 34). The data of patient demographics, comorbidities, operative outcomes, morbidity, mortality and long‑term biliary complications were analysed and compared between the groups. Results. Out of a total of 154 patients with confirmed choledocholithiasis, the trans‑ductal approach of LCBDE was applied to 77 patients. In 43 patients, clearance was done with choledochoscope (group CS+) and in 34 patients without it (group CS–). Gallstone related complications and comorbidities did not differ between the groups. Surgery was done 4 days after admission in both groups. Median duration of the operation was significantly shorter in the group CS–, 93 vs 120 minutes (p = 0.036), without any difference in conversion and complication rates. Clearance rate was markedly high in both groups. Conclusions. Transductal laparoscopic common bile duct exploration without choledochoscopy is a time‑saving, safe and effective way for CBD clearance, without additional equipment.

Minimally Invasive Treatment for Cholelithiasis

Gallstone disease, cholecysto- and choledocho-lithiasis, is one of the most common digestive diseases. Most patients with symptomatic cholecystolithiasis are recommended to undergo cholecystectomy to alleviate their symptoms like abdominal pain and jaundice. Approximately 10–20% of patients who undergo cholecystectomy for gallstones have choledocholithiasis. Nowadays, endoscopic and/or laparoscopic approaches are widely accepted as the treatment for patients with gallstone. Patients with cholecystolithiasis are usually treated by laparoscopic cholecystectomy, whereas patients with choledocholithiasis are done by endoscopic sphincterotomy (EST) or laparoscopic common bile duct exploration (LCBDE). Additionally, some cases are treated by biliary reconstruction such as biliary enteric anastomosis. In this chapter, currently available laparoscopic approaches as a minimally invasive surgery are introduced and discussed on the basis of pathogenesis of the gallstone.

P-BN27 Novel technique for safe and efficient cannulation of the cystic and common bile duct

Background Concomitant stones in the common bile duct (CBD) at the time of laparoscopic cholecystectomy (LC) are present in up to 15% of patients. In conjunction with intra-operative cholangiogram (IOC), transcystic common bile duct exploration (TCBDE) enables diagnosis and management of ductal stones in a single stage procedure. However, cannulation of the cystic duct (CD) and CBD can be challenging. With repeated attempts at cannulation, there is increased risk of iatrogenic injury by creating a false passage or perforating the duct. We propose a novel technique for the safe cannulation of the CD and CBD. Methods Once critical view of safety is achieved, a clip is placed distally in the CD and opened with scissors. A flexible tip 80cm guidewire is then preloaded into 5-French ureteric catheter. The complex is then passed into the introducer through the lateral port. A grasper placed at Hartmann’s pouch is used to retract the gallbladder and straighting the CD. Only the guidewire is advanced out of the catheter, traversing the CD and CBD. Once safely advanced, the catheter can then be slid over the guidewire and the guidewire can be removed. IOC and TCBDE can then be performed if indicated. Results This technique was performed on 18 patients who failed CD cannulation during elective and emergency LC for symptomatic gallstone disease in a single center performed by the same surgical team. Median age was 46 years and there was 15 females. A total of 34 cannulations were attempted (in 18 patients) which 100% success rate. There was no added time required for the technique. In majority of cases it decreased the operative time due to quick intubation of CBD. None of the cases required conversion to open surgery. Conclusions The novel technique described for cannulation of the cystic duct uses a Seldinger ‘like’ approach. This is a safe an effective strategy for cannulation of the CD, making the skills more accessible and more time efficient. This should encourage more surgeons to perform IOC and TCBDE where indicated.

O-EGS03 Laparoscopic surgery versus Endoscopy in the management Common Bile Duct Stones: systematic review and Meta-analysis

Background With the advancement in minimally invasive surgery, a 1 stage Laparoscopic Common Bile Duct Exploration (LCBDE) followed by Laparoscopic Cholecystectomy (LC) is a great alternative to removing the gallbladder and CBD stones provided the surgeon possesses the necessary skills. The current guidelines for managing CBD stones is the 2 stage approach, Endoscopic Retrograde Cholangiopancreatography (ERCP) followed by (LC). The objective of this study is to assess whether LCBDE+LC should be the gold standard in managing CBD stones by comparing the clearance rate of common bile duct stones, morbidity, mortality, and the duration of hospital stay with ERCP+LC. Methods This is a systematic review with a meta-analysis that included RCTs of patients who were treated by the LCBDE/LC versus ERCP+LC. The PRISMA guidelines for reporting systemic reviews were followed. RCTs were collected by 2 authors Independently from Cochrane Central Register of Controlled Trials, Medline and Embase. Statistical analysis was carried out by a computer application called Review Manager using the Mantel–Haenszel method, the results were then plotted on a Forest Plot diagram and the 2 groups were then compared. Results 849 patients from 7 RCTs were included in the study, 426 patients in the ERCP+LC arm and 423 in the LCBDE/LC arm. According to the Meta-analysis, Laparoscopic Common Bile Duct Exploration with Cholecystectomy was significantly superior to ERCP + LC in terms of successful Clearance of CBD stone, mortality rate, and Acute Pancreatitis. but had significantly higher rates in biliary leakages. There were no significant differences in Surgical Site Infections, Haemorrhages, Acute Cholangitis, Perforations, or duration of hospital stay between the two arms. Conclusions The current evidence suggests that LCBDE/LC is superior in successful CBD stone clearance, mortality, and acute pancreatitis. However, further RCTs will be needed to assess overall Morbidity, surgical site infections, Haemorrhages, Acute Cholangitis, perforations, or duration of hospital stay. The current guidelines must be reviewed to consider LCBDE/LC as the gold standard in managing patients with CBD stones.

P-BN48 Utilising spatial geometry to obtain the ideal needle mount for laparoscopic intracorporeal suturing

Background Intracorporeal suturing is an essential component of any advanced laparoscopic procedure like fundoplication, bypass surgery or common bile duct exploration. Obtaining the appropriate needle mount during suturing can be challenging. Spatial geometry defines points in three-dimensional space. Ergonomics in laparoscopic surgery identifies a manipulation angle of 60o to target as being optimal. This knowledge, in combination with the principles of light reflection can be used to understand needle orientation in laparoscopic suturing. Methods An experiment was designed on a laparoscopic trainer with three participants. Using the principles of spatial geometry and light reflection, four different points were identified on an angle chart and labelled for a right-hand dominant participant as; centre, right off-centre (5.5cm), right lateral (10 cm) and left off-centre (5.5cm). Each participant was instructed to mount the needle at the defined points using light reflection on the needle shaft as a reference guide. Three readings were taken for each position. Mounted angle was defined as the angle between the shaft of needle holder and long axis of the needle. This was measured using a special application and an average value determined for each position. Results The average values for the mounted angle measurements for each spatial position were: Centre(112o), Right off centre(101o), Right lateral (88.8o) and Left off centre (124.6o). Conclusions This study describes a novel and reproducible technique to obtain an ideal needle mount. For a needle mount greater than 100o either the centre position or the left off-centre position should be considered.

O-BN03 Laparoscopic Common Bile Duct Exploration – Delivered within UK NHS Healthcare Framework

Background Cholelithiasis is a common problem in the UK affecting approximately 15% of the population. The incidence of synchronous choledocholithiasis is approximately 10-18%. The approach to bile duct stones is variable. Single stage bile duct exploration and cholecystectomy (LC) vs two stage ERCP followed by LC has been shown to be equally safe and as effective with reduced length of stay and number of procedures. We describe the results of a single, high volume centre performing laparoscopic common bile duct exploration (LCBDE) as an alternative to ERCP. Methods All patients undergoing LCBDE at our institution from November 2013 – July 2021 were included in the study. Data were collected from a prospectively maintained institutional database and data points corroborated by electronic patient data on hospital systems. Results 304 patients underwent LCBDE. Median age was 68 (range 21-94). Most cases were performed as urgent/emergency (n = 204, 67% vs n = 100, 33% elective). Bile duct stones were diagnosed pre-operatively in 32.8% cases (n = 100). Intra-operative diagnosis was made using laparoscopic ultrasound (n = 221, 73%), cholangiogram (n = 44, 15%) or combination of both (n = 31, 10%). Laparoscopic completion rate was 92%. Successful stone clearance rate was 98%. 56% were via choledochotomy and 44% trans-cystic. Incidence of bile leak was 4.9% (n = 15). Median length of stay was 2 days post-operatively (range 0–62). The rate of all complications was 13.2%. The rate of mortality was 0.66%. Conclusions This is the largest single case series of LCBDE published. This study has demonstrated that a safe and effective LCBDE service can be delivered within the NHS, with outcome data comparable to defined performance standards. With the evolution of specialist training, intra-operative imaging +/- LCBDE is likely to be the preferred modality of treatment.

Surgical methods of treatment for cholecystolithiasis combined with choledocholithiasis: six years’ experience of a single institution

Introduction The optimal treatment of choledocholithiasis combined with cholecystolithiasis remains controversial. Common surgical methods vary among endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC), laparoscopic transcystic common bile duct exploration (LTCBDE), laparoscopic transductal common bile duct exploration (LCBDE) with or without T-tube drainage. The purpose of this study is to evaluate the safety and effectiveness of surgical methods and to determine the appropriate procedure for patients with cholecystolithiasis combined with choledocholithiasis. Methods From January 2013 to January 2019, a total of 1555 consecutive patients diagnosed with cholecystolithiasis combined with choledocholithiasis who underwent surgical treatment in Tongji Hospital were retrospectively analyzed. Total 521 patients with intrahepatic bile duct stones underwent LC + LCBDE + T-Tube were excluded from the analysis. At last, 1034 patients who met the inclusion criteria were divided into three groups according to their surgical methods: preoperative ERCP + subsequent LC (ERCP + LC group, n = 275), LC + LCBDE + intraoperative endoscopic nasobiliary drainage (ENBD) + primary duct closure (Tri-scope group, n = 479) and LC + laparoscopic transcystic CBD exploration (LTCBDE group, n = 280). Clinical records, operative findings and postoperative follow-up were collected and analyzed. Results There was no mortality in three groups. Common bile duct (CBD) stone clearance rate was 97.5% in ERCP + LC group, 98.7% in Tri-scope group, and 99.3% in LTCBDE group. There were no difference in terms of demographic characteristics, biochemistry findings and presentations, but the Tri-scope group had the biggest diameter and amount of stones and diameter of CBD, the LTCBDE group had the least CBD stones and the biggest diameter of cystic gall duct (CGD). ERCP + LC group have the longest hospital stay (14.16 ± 3.88 days vs 6.92 ± 1.71 days vs 10.74 ± 5.30 days, P < 0.05), also has the longest operative time than others (126.08 ± 42.79 min vs 92.31 ± 10.26 min, 99.09 ± 8.46 min, P < 0.05). Compared to ERCP + LC group, LTCBDE group and Tri-scope group had lower postoperation-leukocyte, shorter surgery duration and hospital stay (P < 0.05). Compared to the Tri-scope group, the LTCBDE group had the shorter hospital stay, extubation time and operation time and less intraoperative bleeding. There were less postoperative complications in LTCBDE group (1.1%) compared to the ERCP + LC group (3.6%) and Tri-scope group (2.2%). Follow-up time was 6 to 72 months. Four patients in ERCP + LC group and 5 in Tri-scope group reported recurrent stones. Conclusion All the three surgical methods are safe and effective. Tri-scope approach and LTCBDE approach have superiority to preoperative ERCP + LC. LC + LTCBDE shows priority over Tri-scope approach, but should be performed in selected patients. LC + LCBDE + T-Tube can be an alternative management if the other three procedures were failed. The surgeons should choose the most appropriate surgical procedure according to the preoperative examination results and intraoperative situation.