Laparoscopic CBD exploration using a V-shaped choledochotomy

Kim et al. BMC Surgery Laparoscopic CBD exploration using a V-shaped choledochotomy Eun Young Kim 0 Soo Ho Lee 0 Jun Suh Lee 0 Tae Ho Hong 0 0 Department of Hepatobiliary and Pancreatic Surgery, College of Medicine , Seoul St. Mary's Hospital, The Catholic University of Korea , Seoul , Korea Background: Laparoscopic common bile duct exploration (LCBDE) is a treatment modality for choledocholithiasis. The advantages of this technique are that it is less invasive than conventional open surgery and it permits single-stage management; however, other technical difficulties limit its use. The aim of this article is to introduce our novel technique for LCBDE, which may overcome some of the limitations of conventional LCBDE. Since December 2013, ten patients have undergone LCBDE using a V-shaped choledochotomy (V-CBD). After the confluence of the cystic duct and the CBD were exposed, a V-shaped incision was made along the medial wall of the cystic duct and the lateral wall of the common hepatic duct, which comprise two sides of Calot's triangle. The choledochoscope was inserted into the lumen of the CBD through a V-shaped incision, and all CBD stones were retrieved using a basket or a Fogarty balloon catheter or were irrigated with saline. After CBD clearance was confirmed using the choledochoscope, the choledochotomy was closed with the bard absorbable suture material known as V-loc. Results: The diameter of the CBD ranged from 8 to 30 mm, and the mean size of the stones was 11.6 8.4 mm. The mean operative time was 97.8 30.3 min, and the mean length of the postoperative hospital stay was 6.0 4.6 days. All patients recovered without any postoperative complications, except for one patient who developed postoperative pancreatitis. No conversions to laparotomy were observed, and there were no recurrent stones and no need of T-tube insertion. Conclusions: This report suggests that our novel technique, known as V-CBD, may represent a feasible and straightforward procedure for treating choledocholithiasis, especially when the CBD is not dilated. Choledocholithiasis; Cholelithiasis; Laparoscopy - Background Surgical common bile duct (CBD) exploration is one of the treatment modalities for choledocholithiasis, which is the second most common complication of cholelithiasis, occurring in approximately 1015 % of cholelithiasis patients [1, 2]. This approach has advantages over endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST), which is a widely used treatment for choledocholithiasis but carries a significant risk of complications such as acute pancreatitis, duodenal perforation, bleeding, and, importantly, iatrogenic injury to the muscles of the sphincter of Oddi [3, 4]. With advances in laparoscopic techniques and instruments, laparoscopic CBD exploration (LCBDE) has been performed more frequently, and there have been many reports that laparoscopic choledocholithotomy is less invasive than open surgery [5, 6]. However, in some patients with a narrow CBD, LCBDE is associated with a high risk of postoperative CBD stricture and bile leakage due to technical difficulty. To prevent these complications, surgeons have inserted T-tubes during LCBDE; however, T-tube insertion is nevertheless associated with complications, including infections that ascend through the drain, dislocation of the T-tube (which results in bile leakage), and most importantly, patient inconvenience due to prolonged T-tube placement [7]. Surgeons have proposed a variety of techniques for laparoscopic choledocholithotomy [1, 6, 810], although there remains no consensus as to the best surgical treatment method. The aim of this article is to describe our novel technique for LCBDE, which we have termed laparoscopic CBD exploration through a V-shaped choledochotomy (V-CBD). This novel approach may help to overcome the limitations of conventional LCBDE for the surgical treatment of choledocholithiasis. Methods Since December 2013, a total of 10 patients who were diagnosed with concomitant choledocholithiasis and cholelithiasis have undergone surgery using the novel technique of V-CBD at the Department of Surgery, Seoul St. Marys Hospital. In patients with concomitant cholelithiasis and choledocholithiasis, the treatment paradigm at our center is to initially perform ERCP to treat the choledocholithiasis, which is then followed by laparoscopic cholecystectomy (LC). However, V-CBD has been selectively used in patients who are not candidates for ERCP (due to conditions such as a history of total gastrectomy, periampullary diverticulum, large and impacted stones, or unavailability of ERCP equipment or endoscopists). Preoperative diagnosis was confirmed according to clinical features, laboratory results and radiologic tests including magnetic resonance cholangiopancreatography or computed tomography (CT) scan. In patients with septic shock or who had findings indicating the progression of biliary sepsis (such as delirium or uncontrollable fever despite antibiotic treatment), patients were diagnosed as having acute cholangitis and were initially managed with conservative treatment and resuscitated before any intervention. If patients were felt to be surgical candidates, V-CBD was used regardless of the size or number of stones and the history of previous upper abdominal operations. All medical data were prospectively collected, including the following: demographic and clinical features (age, sex, American Society of Anesthesiologists (ASA) grade, body mass index (BMI) and preoperative laboratory results); disease characteristics (size and number of stones, diameter of the CBD and the presence of gallstone pancreatitis); and surgical outcomes (CBD clearance, operative time, conversion to laparotomy, length of postoperative hospital stay, postoperative morbidity and mortality). This study was approved by the ethics committee at our institution (Institutional Review Board of Seoul St. Marys hospital, College of Medicine, the Catholic University of Korea, IRB code: KC14RISI0814) and all the patients provided their informed consent for the publication of this study. Laparoscopic choledocholithotomy using a V-shaped choledochotomy All patients were placed in the supine position under general anesthesia, and the surgeon and second assistant (who held the laparoscope) were positioned to the left side of the patient. The first assistant stood on the opposite side. For the procedure, we used the following four trocars: one 10-mm trocar on the transumbilicus for the scope; one 5-mm trocar on the subxiphoid process for the flexible choledochoscope; and an additional two 5-mm trocars for the surgeons working channel (one at the right subphrenic area and the other at the right anterior axillary line). The procedure was initiated by dissecting Calots triangle carefully to expose the confluence of the cystic duct and the common hepatic duct (CHD). After the cystic artery was clipped and excised (...truncated)