Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery

Summary

Programmed surgery based on surgical methods and anatomical markers helps shorten the operation time, reduce complications, and improve the safety of the surgery. This study investigated and summarized the surgical methods and anatomic markers of laparoscopic common bile duct exploration in patients with a history of biliary tract surgery.

Abstract

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs easily when performing another operation for laparoscopic common bile duct exploration (LCBDE), which was once considered a relative contraindication. In view of the limitations of the current surgical technique, this study summarized the surgical approaches and crucial anatomical landmarks for reoperation for LCBDE. Four general surgical approaches were proposed to expose the common bile duct, including the ligamentum teres hepatis approach, the anterior hepatic duodenal ligament approach, the right hepatic duodenal ligament approach, and the hybrid approach. Additionally, this study highlighted seven crucial anatomical landmarks: the parietal peritoneum, the gastrointestinal serosa, the ligamentum teres hepatis, the inferior margin of the liver, the gastric antrum, the duodenum, and the hepatic flexure of the colon, which were helpful to safely separate abdominal adhesions and expose the common bile duct. Moreover, to shorten the time of choledocholithotomy, a sequential method was innovatively applied for the removal of the stones in common bile duct. Mastering the above surgical approaches, including identifying crucial anatomical landmarks and adopting the sequential method will improve the safety of reoperation for LCBDE, shorten the operation time, promote the fast recovery of patients, reduce postoperative complications, and contribute to the popularization and application of this technique.

Introduction

Choledocholithiasis is one of the most common biliary tract diseases, with a high recurrence rate¹. Because recurrent choledocholithiasis often involves multiple stones, coupled with the fact that endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) may damage the function of Oddi's sphincter as well as cause repeated retrograde biliary tract infections, patients with recurrent choledocholithiasis often require two or more surgical operations².

With the popularization of minimally invasive surgery and the advancement of laparoscopic techniques, laparoscopic common bile duct exploration (LCBDE) has been widely used in clinical practice, thanks to such advantages as minimal trauma, rapid recovery, and preservation of the function of Oddi's sphincter³. Abdominal adhesions in patients with recurrent choledocholithiasis lead to changes in anatomical structure, so these patients are susceptible to a secondary injury in a subsequent bile duct exploration. Therefore, abdominal adhesions have been considered a contraindication of laparoscopic surgery^4,5. With further technological development, LCBDE has been preliminarily confirmed to be feasible in patients with a history of biliary tract surgery^6,7,8.

However, relevant studies have been limited, and more in-depth research into this surgical technique is still needed. Programmed operations for LCBDE are often lacking, especially for patients with extensive abdominal adhesions. Based on this situation, the present study aims to develop a programmed procedure by investigating the surgical approaches and anatomical landmarks of LCBDE in patients with a history of biliary tract surgery. A programmed operation based on surgical approaches and anatomical landmarks can help to shorten the operation, reduce complications, and improve surgical safety^9,10.

Protocol

A total of 177 patients with a history of biliary tract surgery who underwent LCBDE between September 2010 and December 2021 were included. This study was approved by the institutional review board in The First Affiliated Hospital of Jinan University. All patients provided written informed consent.

1. Inclusion criteria

1. Include patients with more than two stones in the common bile duct (CBD).
2. Include patients with CBD stones that have a total diameter of ≥20 mm.
3. Include patients with a CBD diameter of ≥10 mm.

2. Exclusion criteria

1. Exclude patients with hepatolithiasis.
2. Exclude patients with acute obstructive suppurative cholangitis.
3. Exclude patients with a Child-Pugh liver function of class B or class C.
4. Exclude patients with scheduled simultaneous biliary anastomosis.
5. Exclude patients with an intolerance to general anesthesia due to a poor general condition.

3. Preoperative preparation

1. Administer preoperative blood tests including a complete blood count, liver and renal function test, and coagulation function test.
2. Administer preoperative hepatobiliary color Doppler ultrasound, upper abdominal computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP).

4. Establishment of pneumoperitoneum and trocar placement under general anesthesia with tracheal intubation

1. Use a Veress needle to establish pneumoperitoneum routinely (Veress method)¹¹.
   1. Make a 10 mm long incision on the skin below the umbilicus, then clamp and lift up the skin on both sides of the incision. Insert the Veress needle into the abdominal cavity through the incision. Then, inject carbon dioxide gas and maintain a pneumoperitoneum pressure of 12 mmHg.
2. If the Veress method fails, change to the open method (Hasson method)¹¹.
   1. Using the conventional laparotomy method, incise the abdominal wall layer by layer to the depth along the skin incision made by the Veress method to reach the abdominal cavity. Place the observation port into the abdominal cavity through this incision. Inject carbon dioxide gas and maintain a pneumoperitoneum pressure of 12 mmHg.
3. Place the observation port (the first trocar) around the umbilicus as far as possible to fully explore the abdominal cavity. At the same time, keep the first trocar at least 5 cm away from the previous open incision, or at least 2 cm away from the previous laparoscopic incision, to avoid damage to the intestine adhered to the abdominal wall.
4. According to the adhesion situation observed in abdominal cavity exploration, arrange the trocars typically in a triangular shape with the surgical area as the target. At the same time, take the separation of adhesions, choledochoscopic lithotomy, and T-tube and drainage tube indwelling into consideration.

5. Surgical approaches

1. Hepatic round ligament approach: Separate and release the abdominal adhesions along the hepatic round ligament to the inferior liver margin, and then to the hepatic hilum in order to expose the CBD.
2. Anterior hepatoduodenal ligament approach: Separate the duodenum from the hepatic hilum downward to expose the CBD anterior to the hepatoduodenal ligament.
3. Right hepatoduodenal ligament approach: Separate the hepatic flexure of the colon, adhered to the hepatic hilum, from the hepatic hilum, starting from the right lateral side of the hepatoduodenal ligament downward to expose the area between the right subhepatic space and the omental foramen, thereby determining the position of the CBD.
4. Hybrid approach: Combine two or three of the above approaches.
   NOTE: This mainly depends on the location of adhesion.
   1. If there is adhesion in the middle of the anterior abdominal wall, use the hepatic round ligament approach.
   2. If there is adhesion in the front and on both sides of the CBD, use the anterior hepatoduodenal ligament approach.
   3. If there is adhesion in the right upper abdomen, use the right hepatoduodenal ligament approach.
   4. If there is extensive adhesion in the abdominal cavity, use the hybrid approach. The hybrid approach is the most commonly used method in this study.
   5. Use the above three approaches flexibly and alternately, and start the separation from near to far, from simple to complex, and from loose tissues to adhered and dense tissues.

6. Adhesion separation and CBD exposure based on anatomical landmarks

1. Parietal peritoneum and gastrointestinal serosa: Use noninvasive grasping forceps to clamp and pull the gastrointestinal tract adhering to the abdominal wall with appropriate traction tension, and separate and release the adhesions close to the parietal peritoneum and away from the gastrointestinal serosa.
   1. Separate the loose adhesions with a blunt dissection or ultrasonic scalpel, and release the dense adhesions or adhesions involving intestines with scissors to avoid thermal damage (Figure 1).
2. Hepatic round ligament: In patients with a history of biliary tract surgery, there are often mutual adhesions between the gastric antrum, duodenum, liver, and abdominal wall. Find the inferior liver margin by separating the adhesions upward along the hepatic round ligament, and expose the gastric antrum and the duodenum (Figure 2 and Figure 5).
3. Inferior liver margin: After exposing the inferior liver margin through the hepatic round ligament, separate the adhesions downward along the visceral surface of the liver, and further expose the gastric antrum and the duodenum. Separate the adhesions at this location close to the liver, under the principle of injuring the liver rather than the gastrointestinal tract if injury is unavoidable (Figure 3, Figure 4, and Figure 5).
4. Gastric antrum and duodenum: The gastric antrum and the first and second segments of the duodenum tend to move up and seal the first hepatic hilar region through adhesions. Separate the adhesions downward along the visceral surface of the liver from the inferior liver margin and expose the gastric antrum and duodenum. Then, lower the gastric antrum and duodenum to further expose the CBD (Figure 4, Figure 5, and Figure 6).
5. Hepatic flexure of the colon: Separate the adhesions between the omentum, intestine, and abdominal wall of the right upper abdomen, and find the hepatic flexure of the colon. Separate and lower the hepatic flexure of the colon from the right inferior liver margin. Expose the CBD by separating the adhesions from the right subhepatic space to the omental foramen (Figure 3).

7. Sequential lithotomy

1. Laparoscopic lithotomy with forceps: Push the lower segment of the CBD using noninvasive grasping forceps, and squeeze the large stones toward the incision of the CBD. Take out the stones directly using forceps.
2. Laparoscopic lithotomy via blind basket extraction: Insert the stone basket into the CBD and open it. Then, pull the basket up and down repeatedly without choledochoscopic assistance. Take out the stones that cannot be squeezed toward the CBD incision via blind basket extraction, which substantially shortens the time of choledochoscopic lithotomy.
3. Stone removal by flushing the CBD with saline: Insert a silicone tube into the CBD. Use a 50 mL syringe to inject saline into the CBD through the silicone tube and flush out the small stones.
4. Choledochoscopic lithotomy: Insert the choledochoscope into the CBD, and continuously inject saline through the choledochoscope flushing channel. Put the stone extraction basket into the CBD through the instrument channel of the choledochoscope and open it, then take out the stones under the direct vision of the choledochoscope.
5. Lithotripsy: According to the diameter of the CBD, insert the sheath of the nephroscope of appropriate size into the CBD through the abdominal puncture port. Then, insert the nephroscope into the common bile duct through the sheath, and continuously inject saline.
   1. Perform pneumatic ballistic lithotripsy or holmium laser lithotripsy under the direct vision of the nephroscope.

8. T-tube indwelling or CBD primary suture

1. Primary suture the CBD for patients with a definite effect after lithotomy, a CBD diameter of ≥10 mm, and no evident stenosis of the lower segment of the CBD.

Results

This study included 177 patients (mean age: 61.74 ± 5.97 years), including 79 males and 98 females. A total of 69 patients had a history of open cholecystectomy (OC); 36 patients had a history of OC and open common bile duct exploration (OCBDE); eight patients had a history of OC, OCBDE, and left lobe hepatectomy (LLH); three patients had a history of OC, OCBDE, and choledochojejunostomy; 42 patients had a history of laparoscopic cholecystectomy (LC); seven patients had a history of LC and LCBDE; and 12 patients had a hi...

Discussion

The most common cause of choledocholithiasis is stones falling into the CBD through the gallbladder, while some CBD stones can origin from the CBD itself¹. The incidence rate of choledocholithiasis in patients after cholecystectomy is 10%-18%, and 4%-24% of patients with choledocholithiasis have recurrence after the first lithotomy and often require repeated surgery(ies)^12,13. Since the first application of LCBDE in 1991, it has been prove...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Electronic choledochoscope	Olympus	CHF-V	/
Harmonic scalpel	Ethcion	HAR36	/
Stone basket	Cook	NTSE-045065-UDH	/