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

This protocol aims to develop a programmed procedure by investigating the surgical approaches and anatomical landmarks of laparoscopic common bile duct exploration, or 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 time, reduce complications, improve surgical safety, and further promote the application of this technique. In the 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 helium to expose the common bile duct or CBD.

In the anterior hepatoduodenal ligament approach, separate the duodenum from the hepatic hilum downward to expose the CBD anterior to the hepatoduodenal ligament. In the right hepatoduodenal ligament approach, separate the hepatic flexure of the colon adhered to the hepatic hilum, starting from the right lateral side of the hepatoduodenal ligament downward to expose the area between the right sub hepatic space and the omental foramen, thereby determining the position of the CBD. In the hybrid approach, combine two or three of the demonstrated approaches, which mainly depend on the location of adhesion.

If there is adhesion in the middle of the anterior abdominal wall, use the hepatic round ligament approach. If adhesion exists in the front and on both sides of the CBD, use the anterior hepatoduodenal ligament approach. If there is adhesion in the right upper abdomen, use the right hepatoduodenal ligament approach.

Use the hybrid approach if there is extensive adhesion in the abdominal cavity. Use all 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. Identify the parietal peritoneum and gastrointestinal cirrhosa.

Use noninvasive grasping forceps to clamp and pull the gastrointestinal tract, adhering to the abdominal wall with the appropriate traction tension. Then, separate and release the adhesions close to the parietal peritoneum and away from the gastrointestinal cirrhosa. Separate the loose adhesions with a blunt dissection or ultrasonic scalpel.

Then, release the dense adhesions or adhesions involving intestines with scissors to avoid thermal damage. Next, identify the hepatic round ligament landmark. 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. 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 duodenum. If the injury is unavoidable, separate the adhesions close to the liver under the principle of injuring the liver rather than the gastrointestinal tract.

The gastric antrum and the first and second segments of the duodenum tend to move up and seal the first hepatic hilar region through the 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 expose the CBD further.

To expose the CBD by identifying the 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.

To perform 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. Remove the stones directly using forceps. To perform laparoscopic lithotomy via blind basket extraction, insert the stone basket into the CBD and open it.

Then, repeatedly pull the basket up and down without colodicoscopic assistance. Remove the stones that cannot be squeezed toward the CBD incision via blind basket extraction, which substantially shortens the time of the colodicoscopic lithotomy. To remove the stones by CBD flushing with saline, insert a silicone tube into the CBD.

Use a 50 milliliter syringe to inject saline into the CBD through the silicone tube and flush out the small stones. To perform colodicoscopic lithotomy, insert the colodicoscope into the CBD and continuously inject saline through the colodicoscope flushing channel. Put the stone extraction basket into the CBD through the instrument channel of the colodicoscope.

Open the basket and then take out the stones under the direct vision of the colodicoscope. A total of 174 patients successfully underwent CBD exploration and three patients were converted to laparotomy due to intraoperative hemorrhage of the CBD wall. The mean operation time was approximately 163.72 minutes.

The mean intraoperative blood loss was approximately 87.51 milliliters. and the time to the first flatus was 28.94 hours. The mean postoperative drainage volume was approximately 196.27 milliliters.

And the length of hospital stay was 6.93 days. The postoperative complication rate was 9.0%There were three cases of postoperative bile leakage, one case of postoperative bleeding, five cases of residual stones, one case of abdominal infection, and six cases of incision infection. For successful surgical outcomes, it is crucial to take utmost care while performing adhesion separation and CBD exposure based on anatomical landmarks.