Laparoscopic Common Bile Duct Exploration Followed by Primary Suture Using a Modified Bile Duct Incision

Summary

Cholecystolithiasis with common bile duct stones is a common disease; however, traditional common bile duct exploration has its own limitations. We propose a modified micro incision for laparoscopic common bile duct exploration aimed at reducing complication rates.

Abstract

Cholecystolithiasis is a common clinical disease, and 10-15% of patients with cholecystolithiasis have common bile duct (CBD) stones. Laparoscopic CBD exploration (LCBDE) followed by primary closure has proven to be safe and cost-effective for treating CBD stones and is typically performed via transcystic and transductal approaches. However, traditional LCBDE with choledochotomy may lead to biliary stricture and leakage, and performing choledochoscopy in transcystic LCBDE may be challenging because of the narrow cystic duct. To reduce the incidence rate of biliary stricture and leakage and increase the success rate of choledochoscopy, we propose a modified technique for bile duct incision. We performed LCBDE via a micro longitudinal incision extended along the cystobiliary junction toward the CBD instead of the traditional anterior wall of the CBD or purely transverse transcystic incision. Our micro incision size on CBD only ranged from 5 to 10 mm according to the size of the CBD stones. Using this micro incision technique, which is less invasive, resulted in easier exploration of the CBD and preservation of the ductal wall integrity. This approach encourages surgeons to use primary closure and may be considered a viable alternative choice for patients with ductal stones in the future.

Introduction

Cholelithiasis is among the most common clinical diseases in general surgery, and 10%-15% of patients concurrently experience cholelithiasis and choledocholithiasis¹. Common bile duct (CBD) primary closure, a procedure typically performed after biliary exploration or removal of biliary stones involves direct closure of the CBD incision and is performed to maintain the normal anatomical structure and biliary flow^2,3. Laparoscopic cholecystectomy (LC) + laparoscopic CBD exploration (LCBDE) is considered an effective treatment option for patients with both gallbladder and CBD stones⁴, and its safety and efficacy have been previously reported^3,5. With the development of laparoscopic techniques and medical devices, surgeons can now perform LCBDE using different approaches, including the transcystic and transductal approaches. Furthermore, in the last decade, significant advances have been made with LCBDE with primary sutures, which is gradually replacing the T-tube drainage procedure^6,7.

However, complications are unavoidable in LCBDE and are primarily related to CBD resection (biliary leakage and stenosis). Postoperative bile leakage and bile duct stenosis can occur due to insufficient suturing or inadequate closure of the CBD⁸; these complications may cause abdominal infection and liver function damage, which can significantly delay recovery, increase the length of hospital stay, and lead to higher morbidity and mortality rates. Hence, to reduce the incidence rate of bile leakage, some surgeons tend to use T-tube drainage after LCBDE. However, carrying a T-tube for several weeks is uncomfortable for the patients. Furthermore, biliary leakage may occur if the T-tube is displaced. Therefore, it is vital to choose the appropriate incision and drainage process.

A transcystic approach to CBD exploration has been proposed to avoid CBD damage and eliminate the subsequent need for a T tube^9,10. Nevertheless, the transcystic procedure is sometimes limited to patients presenting with a dilated cystic duct and poses challenges when addressing large stones^11,12. Hence, the generalization of transcystic LCBDE with primary closure is currently restricted¹³.

To minimize CBD damage and optimize the use of the cystic duct, we propose a modified micro incision starting from the cystobiliary junction to the CBD. This technique is deemed suitable for patients with a non-dilated cystic duct because the incision contains both the cystobiliary junction and CBD. Furthermore, the technique allows surgeons to perform cholangioscopy and the primary sutures after LCBDE more easily. Further, a shorter incision on the CBD means less damage to the CBD, which can lead to lower postoperative biliary leakage and stenosis rates.

Protocol

This protocol was approved by the Ethics Committee of Dongguan Tungwah Hospital, and written informed consent was obtained from all patients who underwent surgery.

1. Operating setting and anesthesia

1. Position the patient in a supine position with the head elevated at 30°. Administer general anesthesia via a laryngeal mask or tracheal intubation.
   1. To follow this protocol, for induction of anesthesia, use Sufentanil 0.3-0.5 µg/kg intravenous injection for analgesia, Propofol 1.5-2.5 mg/kg intravenous injection for sedation and loss of consciousness, and Vecuronium 0.1 mg/kg intravenous injection for muscle relaxation before endotracheal intubation. Use Sevoflurane for maintenance of anesthesia: maintain an end-tidal concentration of 1-1.5 MAC. Administer a continuous infusion of Propofol at 4-8 mg/(kg·h) or aTarget-Controlled Infusion (TCI) to maintain a bispectral index value of 40-60.
2. Position the surgeon and second assistant to the left of the patient, at the head and foot, respectively. Position the first assistant to the right of the patient (Figure 1).

2. Surgical technique

1. Insert the subumbilical trocar for the camera and establish the epigastric port (10 mm), right midclavicular port (5 mm), and right anterior axillary line port (5 mm) under direct vision. The distribution of these four trocars is shown in Figure 1.
2. Position the patient in 20° reverse Trendelenburg with left lateral tilt for better visualization. Maintain pneumoperitoneum at 12 mmHg to create working space.
3. Grasp the neck of the gallbladder or Hartmann's pouch with grasping forceps and apply traction in the right upper direction.
4. Incise the serosa overlying the cystic duct, clear lymphatic tissue, and skeletonize the cystic artery.
5. Ligate the cystic artery; then, completely dissect the cystic duct up to the cystobiliary junction.
6. Utilize atraumatic graspers to engage the seromuscular layer of the proximal cystic duct, avoiding full-thickness compression. Apply anterolateral traction to achieve optimal cystic duct-CBD angulation. Maintain sufficient but not excessive tension to prevent ductal avulsion. Use locking clips in the distal cystic duct to temporarily prevent bile flow.
   NOTE: To ligate the cystic artery, surgeons typically use surgical clips, sutures, or energy devices. We prefer sutures and energy devices to surgical clips because sometimes, clips in the Calot's triangle may obstruct surgeon's view and influence the next procedure. The optimal angle between the cystic duct and CBD does not have a fixed degree and usually 45-60° will be easier for a choledochoscope to enter the CBD.
7. Make a micro longitudinal incision extended along the cystobiliary junction toward CBD (Figure 2A) using electric hooks or scissors. Ensure that the incision size ranges from 5 mm to 10 mm according to the size of the stones.
   NOTE: This incision is different from the traditional anterior wall of the CBD (Figure 2B) or transverse transcystic incision (Figure 2C).
8. Perform choledochoscopy using a 3 mm or 5 mm choledochoscope depending on the diameter of the cystic duct. Remove CBD stones in the basket; if impacted stones at the papilla level obstruct access to the basket, employ electrohydraulic lithotripsy to fragment the stones and collect them with the basket later.
9. Reconfirm the clearance of CBD stones. Make sure the irrigation water flows smoothly through the CBD and the sphincter of Oddi works well.
10. Close the incision primarily from the cystobiliary junction to the CBD anterior wall with a 5-0 Polydioxanone suture.
    NOTE: We prefer continuous sutures to interrupted sutures owing to their time efficiency¹⁴. The process of bile duct exploration and primary suture is shown in Figure 3.
11. Close the proximal cystic duct using clips and cut the distal cystic duct. Remove the gallbladder completely.
12. Confirm the absence of bile leakage and stenosis, then place a drainage tube near the CBD and pull it through the right anterior axillary line port.

Results

Between March 2022 and July 2024, LC + LCBDE was performed on 216 patients in our department. Transcystic LCBDE with micro incision followed by primary suture was performed on 42 patients (19.4%); traditional LCBDE + LC followed by primary suture was performed on 90 patients (41.6%); and 86 patients underwent LCBED + LC followed by T-tube drainage (40%).

We compared the modified transcystic micro incision group (42 patients) and traditional LCBDE + LC with primary suture group (90 patients). A...

Discussion

Currently, the transcystic LCBDE followed by primary closure is deemed the least invasive procedure and has the advantages of preserving the integrity of the major ductal wall and avoiding routine drainage of the CBD, which helps decrease the incidence rate of surgery-related complications (leakage and stenosis)¹⁵. In some cases, small-caliber choledochoscope may be the only option when the cystic duct is narrow, which can increase the incidence of residual stones and the rate of secondary surgeri...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Drainage tube (5 mm x 1100 mm)	Jiangsu Yangtze River		for draining fluid accumulations and blood
Electronic choledochoscope	OLYMPUS		for bile duct exploration
Electrosurgical Unit	Shanghai Hutong		for cutting and coagulating tissues
Hem-o-lok	Teleflex		for the ligation and anastomosis of blood vessels and tissues
‌Insuffator for laparoscopy‌	OLYMPUS		for insufflating carbon dioxide gas
Laparoscope	STORZ		for laparoscopic surgery
Laparoscopic Dissecting Forceps	Richard Wolf		for dissecting and grasping tissue
Laparoscopic Grasping Forceps	Richard Wolf		for clamping tissue
Laparoscopic Needle Holder	Kanger		for grasping and manipulating suturing needles
Laparoscopic Scissors	Richard Wolf		for cutting various tissues
Polydioxanone suture	Johnson & Johnson		for incision suturing
Propofol	FRESENIUS KABI		for anaesthesia
Screen	SONY		for showing images
Sevoflurane	Jiangsu Hengrui		for anaesthesia
SPSS ver22.0 (Statistical Package for the Social Sciences)	IBM		for data management, statistical analysis, graphical presentation, and predictive analytics
Sufentanil	Eurocept BV		for anaesthesia
Trocar (10 mm x 100 mm and 5 mm x 100 mm)	Unimicro		for puncturing the abdominal wall
Vecuronium	Zhejiang Xianju		for anaesthesia