Laparoscopic choledocholithotomy and transductal T-tube insertion with indocyanine green fluorescence imaging and laparoscopic ultrasound: A case report

BACKGROUND Laparoscopic choledocholithotomy for a large impacted common bile duct(CBD)stone is a challenging procedure because of the technical difficulty and the possibility of postoperative complications,even in this era of minimally invasive surgery.Herein,we present a case of large impacted CBD stones.CASE SUMMARY A 71-year-old man showed a distal CBD stone(45 mm×20 mm)and a middle CBD stone(20 mm×15 mm)on computed tomography.Endoscopic retrograde cholangiopancreatography failed due to the large size of the impacted stone and the presence of a large duodenal diverticulum.Laparoscopic choledocholithotomy was decided,and we used a near-infrared indocyanine green fluorescence scope to detect and expose the supraduodenal CBD more accurately.Then,the location,size,and shape of the stones were detected using a laparoscopic intraoperative ultrasound.The CBD was opened with a 2-cm-sized vertical incision.After irrigating several times,two CBD stones were removed with the Endo BabcockTM.T-tube insertion was done for postoperative cholangiography and delayed the removal of remnant sludge.The patient had no postoperative complications.CONCLUSION Laparoscopic choledocholithotomy by transcholedochal approach and transductal T-tube insertion is a safe and feasible option for large-sized impacted CBD stones.

Comprehensive and innovative techniques for laparoscopic choledocholithotomy:A surgical guide to successfully accomplish this advanced manipulation

Surgeries for benign diseases of the extrahepatic bile duct(EHBD) are classified as lithotomy(i.e., choledocholithotomy) or diversion(i.e.,choledochojejunostomy). Because of technical challenges, laparoscopic approaches for these surgeries have not gained worldwide popularity. The right upper quadrant of the abdomen is advantageous for laparoscopic procedures,and laparoscopic choledochojejunostomy is safe and feasible. Herein, we summarize tips and pitfalls in the actual procedures of choledocholithotomy.Laparoscopic choledocholithotomy with primary closure of the transductal incision and transcystic C-tube drainage has excellent clinical outcomes;however, emergent biliary drainage without endoscopic sphincterotomy and preoperative removal of anesthetic risk factors are required. Elastic suture should never be ligated directly on the cystic duct. Interrupted suture placement is the first choice for hemostasis near the EHBD. To prevent progressive laceration of the EHBD, full-layer interrupted sutures are placed at the upper and lower edges of the transductal incision. Cholangioscopy has only two-way operation; using dedicated forceps to atraumatically grasp the cholangioscope is important for smart maneuvering. The duration of intraoperative stone clearance accounts for most of the operative time. Moreover, dedicated forceps are an important instrument for atraumatic grasping of the cholangioscope. Damage to the cholangioscope requires expensive repair. Laparoscopic approach for choledocholithotomy involves technical difficulties. I hope this document with the visual explanation and literature review will be informative for skillful surgeons.

Comprehensive review on small common bile duct stones

Common bile duct stones are among the most common conditions encountered by endoscopists.Therefore,it is well researched;however,some items,such as indications for endoscopic papillary balloon dilatation(EPBD),safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant,selection strategy for retrieval balloons and baskets,lack adequate evidence.Therefore,the guidelines have been updated with new research,while others remain unchanged due to weak evidence.In this review,we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation,stone retrieval devices,difficult-to-treat cases,troubleshooting during the procedure,and complicated cases of cholangitis,cholecystolithiasis,or distal biliary stricture.

Which octogenarian patients are at higher risk after cholecystectomy for symptomatic gallstone disease? A single center cohort study

BACKGROUND Incidence of gallstones in those aged≥80 years is as high as 38%-53%.The decision-making process to select those oldest old patients who could benefit from cholecystectomy is challenging.AIM To assess the risk of morbidity of the“oldest-old”patients treated with cholecystectomy in order to provide useful data that could help surgeons in the decision-making process leading to surgery in this population.METHODS A retrospective study was conducted between 2010 and 2019.Perioperative variables were collected and compared between patients who had postoperative complications.A model was created and tested to predict severe postoperative morbidity.RESULTS The 269 patients were included in the study(193 complicated).The 9.7%of complications were grade 3 or 4 according to the Clavien-Dindo classification.Bilirubin levels were lower in patients who did not have any postoperative complications.American Society of Anesthesiologists scale 4 patients,performing a choledocholithotomy and bilirubin levels were associated with Clavien-Dindo>2 complications(P<0.001).The decision curve analysis showed that the proposed model had a higher net benefit than the treating all/none options between threshold probabilities of 11%and 32%of developing a severe complication.CONCLUSION Patients with American Society of Anesthesiologists scale 4,higher level of bilirubin and need of choledocholithotomy are at the highest risk of a severely complicated postoperative course.Alternative endoscopic or percutaneous treatments should be considered in this subgroup of octogenarians.

Choledocholithiasis caused by anatomical variation of cystic duct: A case report

Laparoscopic cholecystectomy(LC)has gradually become the first choice for the treatment of cholecystolithiasis in recent years.Iatrogenic bile duct injury(IBDI)is an important clinical problem in LC.The anatomical variation of the cystic duct increases the probability of IBDI and the difficulty of operation.We present a case of a 44-year-old male with a anatomical variation of the cystic duct complicated with cholecystolithiasis and choledocholithiasis,who successfully underwent choledocholithotomy,choledochoscopic exploration and T-tube drainage surgery.The patient recovered well and was discharged home on postoperative day 10.The T-tube was removed at 1 month postoperatively after cholangiography examination of no choledocholithiasis left.