Single-Incision Plus One-Port Laparoscopic Choledocholithotomy with Primary Suture for Choledocholithiasis

Summary

This study demonstrates that single-incision plus one-port laparoscopic common bile duct exploration with primary suture is a safe, effective, and minimally invasive alternative for choledocholithiasis, offering faster recovery and comparable safety to traditional approaches.

Abstract

The purpose of this study protocol is to describe and verify the safety, feasibility, and efficacy of single-incision plus one-port (S+1) laparoscopic choledocholithotomy with primary suture for the treatment of choledocholithiasis, aiming to balance minimal invasiveness, operative precision, and enhanced patient recovery S+1 group. This study enrolled patients with choledocholithiasis who underwent the target surgical procedure and selected concurrent patients who received traditional multi-port laparoscopic choledocholithotomy with T-tube drainage as the control group. The specific surgical protocol includes placing a transumbilical multi-channel trocar and a 5 or 10 mm subxiphoid auxiliary port to optimize instrument distribution; making a longitudinal incision on the common bile duct (CBD) using an electrified small needle for stone extraction; and suturing the CBD with 5-0 absorbable sutures. Intraoperative choledochoscopy was used to confirm the clearance of stones, and perioperative indicators, including operative time, intraoperative blood loss, postoperative hospital stay, and complication rate, were compared between the two groups. Results showed no statistically significant differences in intraoperative blood loss or total complication rate between the two groups; however, the S+1 group had significantly shorter operative time, postoperative flatus time, and hospital stay. Complications (such as biliary leakage and residual stones) in both groups were resolved by minimally invasive interventions without the need for reoperation. This surgical procedure provides a safe and effective minimally invasive option for the treatment of choledocholithiasis. While avoiding T-tube-related complications, it also has the advantages of cosmetic effect and accelerated recovery, providing a basis for its clinical application in appropriately selected patients.

Introduction

Choledocholithiasis is a prevalent disease in hepatobiliary surgery. Without timely intervention, it may lead to severe complications such as acute cholangitis, obstructive jaundice, and biliary pancreatitis, which can even be life-threatening¹. Currently, surgical treatment remains the mainstay for choledocholithiasis. The traditional surgical approach is laparoscopic common bile duct exploration (LCBDE) combined with T-tube drainage, which can effectively remove stones. However, during the indwelling period of the T-tube, complications such as drainage tube blockage, infection, and electrolyte imbalance are prone to occur. Moreover, long-term T-tube indwelling prolongs patients’ hospital stay, increases the medical burden, and brings inconvenience to their daily lives².​

With the advancement of minimally invasive surgical techniques, primary suture after LCBDE has attracted increasing attention. By directly suturing the bile duct wall, this approach avoids T-tube-related complications and shortens patients’ recovery period³. Meanwhile, the application of single-incision laparoscopic surgery (SILS, defined as laparoscopic surgery performed through a single abdominal incision) further reduces surgical trauma, offering distinct minimally invasive advantages and superior cosmetic outcomes⁴. The cosmetic benefits of SILS are particularly valued by patients, as the single transumbilical incision is well-concealed and results in minimal scarring, which significantly improves postoperative quality of life compared with conventional multi-port laparoscopic approaches⁵. However, pure SILS is prone to the chopstick effect—a phenomenon of instrument interference—that significantly increases surgical difficulty, especially for delicate biliary tract manipulation. To balance the minimally invasive nature and operational convenience, the single-incision plus one-port (S+1) laparoscopic technique has emerged. This hybrid approach retains the minimally invasive characteristics of SILS while improving the flexibility of instrument operation through an additional auxiliary port, providing better exposure and maneuverability for complex biliary tract operations⁶.​

To strengthen the clinical positioning of the S+1 laparoscopic LCBDE with primary suture, clear practical applicability guidance, patient selection considerations, and technical prerequisites are essential. Patient selection criteria for this technique include: (1) patients with confirmed choledocholithiasis (single or multiple stones) without severe acute cholangitis or cholangiectasis; (2) unobstructed distal common bile duct (CBD) confirmed by preoperative imaging (abdominal ultrasound or computed tomography); (3) no history of upper abdominal surgery that may cause intra-abdominal adhesions; and (4) good cardiopulmonary function to tolerate general anesthesia. Technical prerequisites involve proficient laparoscopic suturing skills, familiarity with choledochoscopic stone extraction, and experience in managing minimally invasive biliary tract complications. Despite the theoretical advantages of the S+1 technique, its safety, feasibility, and long-term efficacy in the treatment of choledocholithiasis still require more high-quality clinical evidence to support⁷. Therefore, this study aims to systematically explore the clinical application value of S+1 laparoscopic LCBDE with primary suture in the treatment of choledocholithiasis, so as to provide evidence-based reference for the minimally invasive treatment of this disease.

Protocol

This study was approved by the Ethics Committee of Dongguan Tungwah Hospital, which waived the requirement for informed consent due to the anonymous retrospective design of this study.

1. Patient selection criteria

1. Inclusion criteria: Include participants diagnosed with choledocholithiasis confirmed by preoperative imaging (ultrasound, CT, or magnetic resonance cholangiopancreatography [MRCP]); age 18–80 years; American Society of Anesthesiologists (ASA) classification I–III; common bile duct (CBD) diameter ≥8 mm on preoperative imaging; and provision of written informed consent.
2. Exclusion criteria: exclude participants with acute suppurative cholangitis or severe biliary pancreatitis; intrahepatic duct stones requiring hepatolithotomy or lithotripsy; suspected biliary malignancy or history of biliary tract surgery; CBD diameter <6 mm; history of upper abdominal surgery that would preclude laparoscopic access; coagulopathy (international normalized ratio [INR] >1.5) or uncontrolled bleeding disorders; pregnancy or lactation; and inability to tolerate general anesthesia or pneumoperitoneum.

2. Preoperative investigations

1. Laboratory tests
   1. Perform liver function tests (alanine aminotransferase [ALT], aspartate aminotransferase [AST], total bilirubin [TBil], direct bilirubin [DBil], alkaline phosphatase [ALP], gamma-glutamyl transferase [GGT]).
   2. Perform renal function tests (blood urea nitrogen [BUN], creatinine [Cr]). Perform a complete blood count (CBC) with differential. Perform coagulation profile (prothrombin time [PT], activated partial thromboplastin time [APTT], INR). Perform blood typing and crossmatch. Perform serum amylase and lipase measurements.
2. Imaging and cardiopulmonary evaluation
   1. Perform electrocardiogram (ECG) and chest X-ray. Obtain cardiology consultation if indicated by ECG findings or cardiac history.
   2. Perform color Doppler ultrasound of the hepatobiliary system. Perform contrast-enhanced computed tomography (CT) scan of the upper abdomen or magnetic resonance cholangiopancreatography (MRCP) when indicated.

3. Operative procedure

1. Patient preparation and positioning
   1. Administer general anesthesia with endotracheal intubation following institutional protocols. Position the patient supine with arms extended laterally.
   2. Prepare the surgical field from the nipples to the pubis. Disinfect the skin with 10% povidone-iodine solution; apply sterile drapes.
   3. Insert a nasogastric tube and a Foley catheter to decompress the stomach and bladder.
      Trocar placement and pneumoperitoneum establishment
   4. Make a 15–20 mm curvilinear incision through the umbilicus using a surgical scalpel (Figure 1). Insert a multi-channel single-port device (TriPort or SILS Port) into the peritoneal cavity under direct visualization.
      NOTE: The multi-channel port typically accommodates three to five instruments simultaneously, including a 5 mm or 10 mm laparoscope.
   5. Insufflate carbon dioxide (CO₂) through one channel to maintain intra-abdominal pressure at 12–14 mmHg.
   6. Make a 5 mm or 10 mm incision in the midline or right paramedian subxiphoid region. Insert a 5 mm or 10 mm trocar through this incision under laparoscopic guidance (Figure 1, Figure 2).
2. Exposure and dissection
   1. Position the patient in reverse Trendelenburg position with 15° left tilt to displace the gastrointestinal tract and omentum inferiorly.
   2. Insert a 5 mm 30° laparoscope through the umbilical port. Grasp the gallbladder fundus or Hartmann's pouch with atraumatic grasping forceps introduced through the umbilical port; retract superiorly and laterally.
   3. Grasp the infundibulum with a second grasper through the subxiphoid port; apply counter-traction. Incise the serosa overlying Calot's triangle using electrocautery (hook or spatula, 20–30 W coagulation current).
   4. Clear lymphatic and adipose tissue to expose the cystic duct and cystic artery. Ligate the cystic artery with locking polymer clips (5 mm, e.g., Hem-o-lok) placed proximally and distally; divide with laparoscopic scissors.
   5. Dissect the cystic duct circumferentially to its junction with the common bile duct (CBD).
3. Cystic duct management and choledochotomy
   1. Apply gentle anterolateral traction to the cystic duct using atraumatic graspers on the seromuscular layer only (avoid full-thickness compression).
   2. Place a locking polymer clip (5 mm) on the distal cystic duct adjacent to the gallbladder to temporarily occlude bile flow from the gallbladder.
   3. Straighten a 5-0 polypropylene suture on a round-body needle using a needle holder. Secure a 2-0 silk suture to the needle tail as a safety measure to prevent intra-abdominal needle loss.
   4. Grasp the needle midpoint with a laparoscopic needle holder connected to monopolar electrocautery (20 W cutting current). Make a 10 mm longitudinal incision on the anterior wall of the CBD using the electrified needle (Figure 3A).
      CAUTION: Avoid excessive electrocautery to prevent thermal injury to the posterior bile duct wall.
4. Choledochoscopy and stone extraction
   1. Insert a 5 mm flexible choledochoscope through the subxiphoid trocar. Advance the choledochoscope into the CBD through the choledochotomy.
   2. Examine the proximal (hepatic) and distal (duodenal) segments systematically. Capture visualized stones using a Dormia stone retrieval basket (3F or 4F) introduced through the choledochoscope working channel.
   3. Retrieve stones under direct visualization; repeat until complete clearance is achieved (Figure 3B). Confirm sphincter of Oddi patency by visualizing passage of the choledochoscope into the duodenum or by observing saline flow into the duodenum.
      NOTE: If resistance is encountered during choledochoscope passage, do not force; reassess for stricture or impacted stones.
5. Primary duct closure
   1. Prepare a 5-0 monofilament absorbable suture (polydioxanone, PDS) on a round-body needle (17 mm, 1/2 circle). Close the choledochotomy using either of the following.
      1. Continuous suturing technique: Insert the needle 2 mm from the incision edge, exiting 2 mm from the opposite edge. Take 4–6 bites with 1.5–2 mm spacing between each bite. Maintain consistent tension on the suture to approximate edges without strangulation. Complete the closure with an intracorporeal surgeon's knot followed by three alternating half-hitches.
      2. Interrupted suturing technique: Place 3–5 interrupted sutures with 2 mm spacing. Secure each suture with an intracorporeal surgeon's knot followed by three alternating half-hitches. Ensure all knots are extracanalicular to prevent an intraluminal nidus for stone formation (Figure 3C,D).
         CAUTION: Avoid excessive tension that may cause tissue ischemia or suture tearing.
6. Leak testing and cholecystectomy
   1. Place a sterile gauze pad over the sutured CBD. Irrigate the supraduodenal area with normal saline.
   2. Observe for bile staining on the gauze for 3–5 min. If bile leakage is detected, place additional interrupted sutures at the leak site.
   3. Perform cholecystectomy: Retract the gallbladder fundus superiorly and divide the cystic artery between clips if not previously ligated. Divide the cystic duct between locking polymer clips (5 mm) placed proximal (CBD side) and distal (gallbladder side). Dissect the gallbladder from the liver bed using ultrasonic sheers (Harmonic Ace, level 3) or electrocautery (hook, 20–30 W). Extract the gallbladder through the umbilical port within an endo-bag.
7. Completion and drainage
   1. Irrigate the subhepatic space thoroughly with warm normal saline. Suction all irrigant and accumulated fluid. Insert a 19-Fr closed suction drain through the subxiphoid trocar site.
   2. Position the drain tip in the foramen of Winslow under direct vision. Secure the drain to the skin with 2-0 silk suture. Remove all trocars under laparoscopic visualization to confirm hemostasis.
   3. Close the umbilical fascia with 1-0 absorbable interrupted sutures. Approximate skin incisions with 4-0 absorbable subcuticular sutures. Apply sterile dressings.

4. Postoperative management

1. Immediate postoperative care (0–24 h)
   1. Monitor vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation, temperature) every 4 h for the first 24 h.
   2. Administer intravenous fluids (Ringer's lactate or normal saline) at 80–100 mL/h to maintain hydration and electrolyte balance.
   3. Administer intravenous antibiotics (third-generation cephalosporin or alternative based on local protocols) for 24–48 h postoperatively.
   4. Administer hepatoprotective agents (e.g., ademetionine 1000 mg IV daily) if indicated by preoperative liver dysfunction.
   5. Maintain nasogastric tube decompression until return of bowel sounds or passage of flatus.  Maintain Foley catheter until patient is ambulatory (typically 24 h).
2. Recovery and ambulation
   1. Initiate oral water intake (30–50 mL every 2 h) 6 h postoperatively if no nausea or vomiting. Advance to a liquid diet on postoperative day 1, then to a soft diet as tolerated.
   2. Encourage sitting at bedside on postoperative day 0 evening. Assist with ambulation beginning postoperative day 1, minimum 3x daily. Administer analgesics (patient-controlled analgesia [PCA] or intravenous/oral non-steroidal anti-inflammatory drugs [NSAIDs] as needed).
3. Drain management
   1. Record drain output volume and character every 8 h. Remove the drain when: Output is <50 mL/24 h, fluid is serous (not bilious or purulent), no evidence of bile leakage (drain fluid bilirubin < serum bilirubin), typically achieved on postoperative day 3–5.
   2. If bilious output >100 mL/24 h persists, obtain a drain fluid bilirubin measurement and consider ERCP with sphincterotomy and stent placement.
4. Discharge criteria
   1. Discharge when the patient is tolerating oral diet without nausea or vomiting, afebrile for ≥24 h, adequate pain control with oral analgesics, independently ambulatory, drain is removed (if applicable), normal or near-normal liver function tests (trending toward preoperative baseline), and the patient is educated regarding signs of complications (fever, jaundice, abdominal pain) and follow-up appointment scheduled.

5. Follow-up

1. Schedule an outpatient clinic visits at 2 weeks post-discharge for wound assessment and symptom review.
2. Perform liver function tests at 4 weeks postoperatively.
3. Schedule abdominal ultrasound at 3 months to exclude recurrent stones or biliary stricture. Schedule long-term follow-up annually or as clinically indicated.

Results

Between January 2022 and January 2025, our department performed S+1 laparoscopic common bile duct exploration (LCBDE) with primary suture on 56 patients. During the same period, 55 patients who underwent traditional LCBDE with T-tube drainage were selected as the control group for comparative analysis. All data were expressed as mean ± standard deviation (SD). Inter-group comparisons of significance were analyzed using the chi-square test (χ² test) for categorical data, and continuous data were analyzed using ...

Discussion

The core philosophy of minimally invasive surgery is to continuously pursue reduced trauma and faster recovery while ensuring surgical safety and therapeutic efficacy^8,9. This study integrates the laparoscopic technique with primary suture following common bile duct exploration, as none of the 56 patients in this group developed biliary stricture. Our findings indicate that this combined procedure significantly shortens operative time and accelerates postoperativ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Google Forms	Google LLC	N/A	Used to distribute and collect responses for the online survey
Microsoft Excel	Microsoft Corporation	N/A	Used for data organization and export prior to analysis
PubMed Database	U.S. National Library of Medicine	N/A	Used for literature review and retrieval of references
Questionnaire	Liu D, Sawyer J, Luna A, Aoun J, Wang J, Boachie L, Halabi S, Joe B Perceptions of US Medical Students on Artificial Intelligence in Medicine: Mixed Methods Survey Study JMIR Med Educ 2022;8(4):e38325 URL: https://mededu.jmir.org/2022/4/e38325 DOI: 10.2196/38325	N/A	Validated questionnaire assessing perceptions of AI in medicine, adapted from a previously published study in JMIR Medical Education (2022)
R (Statistical Software)	R Foundation for Statistical Computing	N/A	Used for statistical analysis and data visualization