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....

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<....

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	/