Laparoscopic common bile duct exploration T-tube choledochotomy (LCBDE), also known as laparoscopic choledochotomy, is a minimally invasive surgical technique for effective treatment of common bile duct stones, with the advantages of small trauma, quick recovery, no obvious scars after healing, and relatively short hospitalization. It has the advantages of small trauma, quick recovery, no obvious scars after healing and relatively short hospitalization time. Our department is skilled in laparoscopic cholecystectomy (LC) and LCBDE for the treatment of gallbladder stones combined with common bile duct stones, or LCBDE for the treatment of common bile duct stones. This article briefly introduces the indications, contraindications, advantages, disadvantages and complications of LCBDE to help patients understand the application of this technology.
Indications.
The ideal indications for LCBDE should meet the following four conditions simultaneously.
1, common bile duct stones: gallbladder stones complicated by secondary stones in the common bile duct (LC+LCBDE), or primary common bile duct stones; primary intra- and extra-hepatic bile duct stones without biliary strictures, which can be removed by choledochoscopy without the need for line or biliary intestinal drainage; or common bile duct stones with obstructive jaundice or acute cholangitis.
2, diameter of common bile duct > 1.0 cm.
3.Stones in the common bile duct as a single or several stones.
4, common bile duct stones <1.5cm.
Contraindications.
1.Primary intrahepatic bile duct stones, difficult to remove by choledochoscopy or need to perform hepatectomy.
2.Stenosis of the lower common bile duct, requiring choledointestinal anastomosis.
3.The diameter of the common bile duct is <1.0 cm, and laparoscopic choledochotomy may cause serious side injury and postoperative bile duct stricture.
4.The stones in the common bile duct are too large, and it is difficult to remove the stones with the lithotomy net.
5.Severe adhesions in the abdominal cavity, especially serious adhesions in the hepatic portal, and the common bile duct cannot be dissected and revealed.
6, Other contraindications as in open surgery (various conditions that cannot be treated surgically, such as severe cardiopulmonary insufficiency, coagulation mechanism disorders, etc.).
Relative contraindications.
1.History of upper abdominal surgery.
2, Acute obstructive purulent cholangitis.
3.Multiple common bile duct stones.
With the increase of technical proficiency, relative contraindications can be gradually transformed into relative indications.
Technical advantages.
1, small trauma, fast recovery, in line with patients’ psychological wishes: small wound, small scar after healing, little interference and stimulation to abdominal viscera, fast recovery of intestinal function after surgery, 24-36 hours to resume diet, good patient compliance.
2.Basically eliminate incision-related complications: no worry of incision cracking, incision infection rate is significantly reduced, and there is no incision difficult to heal.
3.Basically eliminated the complications of longer bed rest: early bed activity, low incidence of complications such as pulmonary atelectasis, pulmonary infection, intestinal adhesions, and venous thrombosis of lower limbs in the elderly.
Limitations.
1, the surgical operation is technically demanding and technically difficult, and the precision of surgical operation is much less convenient than open surgery. However, the speed and safety of surgery can be significantly improved after proficiency.
2. Since the choledochoscope is needed to guide the removal of stones in the common bile duct, the diameter of the bile duct and the size of the stones have certain requirements for adaptation, and the operation time is not significantly shortened compared with open surgery.
3.It requires supporting fiberoptic cholangioscope, intraoperative cholangiography and other related equipment.
4.It is not suitable for diffuse intrahepatic bile duct stones and the treatment of bile duct stones that require bile-intestinal anastomosis and hepatic lobectomy.
Complications and prevention.
Laparoscopic biliary exploration and cholecystectomy itself has potential dangers, which can cause a variety of serious complications if not handled properly, including.
1, intraoperative and postoperative bleeding. The key to prevention and treatment lies in strict control of the position of the common bile duct incision and fine operation during surgery.
2. Bile leakage. The key to prevention and treatment is to avoid damage to the common bile duct and the fine technique of suturing the common bile duct.
3.Biliary stricture. The key to prevention and treatment: strict mastery of the indications, precise suturing of the common bile duct, and prevention of bile duct thermal injury.
4. Residual biliary tract stones. The key to prevention and treatment: intraoperative extraction of stones, postoperative imaging before removal of the T-tube and application of choledochoscopy to remove stones via the T-tube common bile duct.
5. Abdominal cavity infection. Prevention and treatment key: prevent bile spillage or leakage into the abdominal cavity, place abdominal drainage, postoperative anti-infection.
6. Accidental injury to other internal organs. Prevention and treatment points: careful operation.
7, pneumoperitoneum-related complications. Preventive measures: appropriate abdominal air pressure, pneumoperitoneum deflated at the end of surgery.
With increased technical proficiency, the chance of the above complications is significantly lower.
Any kind of technology has its own rationality and inherent limitations, and must be combined with the specific circumstances of the patient to choose the application, in order to achieve the most desirable results.