Liu Dongbin1, Xu Dahua[1]
With the wide application of laparoscopy and fiberoptic choledochoscopy in clinical practice, Phillips et al. carried out laparoscopic biliary lithotripsy and T-tube drainage via the common bile duct route [1] and Stoker et al. carried out via the cystic duct route [2]. However, the retention of T-tube brings some inconvenience to patients’ life and care, and there is also a risk of T-tube slippage, and the removal of T-tube can cause bile leakage, long time of patients with tube and prolonged hospital stay. Laparoscopic common bile duct exploration with one-stage suturing has become a feasible surgical procedure for minimally invasive treatment of gallbladder stones combined with extrahepatic bile duct stones. The literature reports that this surgical approach has the advantages of less trauma, less pain, faster recovery, and shorter hospital stay; it reduces patient pain and saves hospital stay and costs, but there are also complications such as bile leakage, postoperative residual stones, bleeding, and bile duct stricture [3]. In this paper, we describe the common complications and management strategies of laparoscopic common bile duct exploration with one-stage suturing. Liu Dongbin, Department of General Surgery, Xuanwu Hospital, Capital Medical University
I. Biliary leakage
Bile leak is a disease in which bile or fluid containing bile continues to leak directly into the abdominal cavity from the bile duct system through abnormal pathways caused by multiple causes. Bile leak is the most common complication of laparoscopic common bile duct exploration surgery accounting for approximately 40% of complications after laparoscopic biliary exploration, and its incidence in cases with one-stage sutures ranges from 1.6 – 22.7% [4-9].
The main reasons for the occurrence of bile leak may include 1, severe preoperative jaundice in patients, severe inflammatory reaction in the distal bile ducts, which remains unresolved after surgery, elevated pressure in the bile ducts, and formation of bile leak; 2, lack of fiberoptic choledochoscopy technique, which causes medically induced damage to the inner wall of the bile ducts during stone extraction, spasm of the sphincter of Oddi or even residual stones in the sphincter [10], resulting in elevated biliary pressure, causing bile leak and direct leakage; 3, laparoscopic suturing technical problems or difficulty, resulting in less than satisfactory suturing, whether interrupted suturing or continuous suturing with poor ligation, unreasonable suture spacing, and unreasonable suture selection for bile leakage at the eye of the needle.
Prevention and treatment of bile leakage after laparoscopic common bile duct exploration with one-stage suturing include: 1. Strictly control the indications for surgery, and a cautious attitude should be taken for cases with obvious bile duct stone impaction, persistent aggravation of jaundice, and prolonged jaundice; 2. Strengthen training in laparoscopic and fiberoptic choledochoscopic techniques to improve laparoscopic suturing techniques and choledochoscopic stone extraction techniques; 3. Be gentle in intraoperative operations, and do not force the choledochoscope and lithotomy mesh basket through The bile duct should not be forced through the end of the common bile duct, so as not to cause edema and stenosis of the end of the common bile duct; 4. Reasonably select absorbable sutures to close the bile duct in all layers, and choose the appropriate suture margin and stitch distance according to the width of the bile duct and the thickness of the bile duct wall; 5. Reasonably select the drainage tube and placement site to maintain effective drainage; 6.
For the bile found in the abdominal drainage on the postoperative day cannot exclude the cause of intraoperative bile duct dissection. Bile leaks that appear after the first postoperative day are usually more likely to heal spontaneously within 72 hours through adequate abdominal drainage. If the bile leakage drainage is still large at 72 hours, ultrasound and CT examination can be considered to clarify the intra-abdominal situation, which can be treated by transendoscopic nasobiliary drainage (ENBD); if more extensive peritonitis manifests and the drainage suddenly stops, abdominal drainage can be considered, and laparoscopic re-exploration or open treatment is necessary.
A total of 132 cases of laparoscopic common bile duct exploration with one-stage suturing were performed in the authors’ unit from December 2009 to October 2014, and 13 cases (9.84%) of bile leakage occurred, of which 12 patients were cured by conservative treatment and 10 cases had bile leakage stopped within 72 hours, with the longest drainage time of 7 days. In one case, the tenth patient in this surgical stage, postoperative bile leak, the drainage suddenly disappeared on the third day, and the patient had fever and total abdominal peritonitis, and intensive CT showed a large amount of fluid around the liver, around the spleen, and in the pelvis. Emergency laparoscopic exploration was performed again. Intraoperatively, it was found that the uppermost suture of the bile duct was spaced too far apart, and the silicone drainage tube left at Winslow was additionally blocked by the omentum. The bile duct was sutured again laparoscopically, drainage was left in place, and the patient was discharged 5 days after reoperation. Lessons learned have made our center pay special attention to: 1. the first stitch of either continuous or interrupted suture should be slightly higher than the incision site, because the first stitch is often pulled by the next suture to form a bile leak; 2. the gallbladder is not removed first, the bile duct is explored, and the gallbladder is removed after suturing, so that the gallbladder can be pulled to obtain a good exposure of the biliary field, but also to allow some time to observe the bile duct for bile leakage; 3. , the drainage tube is chosen to have an internally supported Pan’s drain, placed at the lateral edge of the right liver, a position that is not only a low point of drainage flux in the ambulatory abdominal cavity, but in addition the omentum does not generally reach this height to block the drainage tube [11].
For patients with significant manifestations of inflammation in the distal common bile duct and long duration of jaundice, the literature reports that retention of a timed off J-tube in the bile duct,can effectively prevent the occurrence of bile leak and bile duct stricture after laparoscopic common bile duct exploration with one-stage suture [12]. Or preoperative and intraoperative ENBD drainage can be performed to reduce the occurrence of bile leak. The latter has also been explored in the author’s unit to achieve better results [3,11].
II. Residual stones
Residual stones after biliary stone surgery are cases of re-discovery of intraciliary stones within 2 years after lithotripsy. The incidence of residual stones after laparoscopic common bile duct exploration with one-stage suturing has been reported in the literature to be 0-2.7% [4,6,7]. The comprehensive literature on the low incidence of residual stones in patients undergoing one-stage suturing is closely related to the choice of surgical indications before laparoscopic common bile duct exploration with one-stage suturing, and cases with excessive stones in the bile duct are mostly selected for the procedure with indwelling T-tube. For residual stone management, postoperative endoscopic sph incterotomy (EST) was firstly chosen to remove the stones. In our center, there were 2 postoperative residual common bile duct stones out of 132 cases, with an incidence of 1.52%. 4 and 5 stones were removed intraoperatively, and both patients developed acute cholangitis such as fever and jaundice again within 1 month after surgery. The number of stones in the common bile duct should be evaluated before surgery and compared with the number of stones removed during surgery.
Recurrence of stones
Postoperative stone recurrence refers to bile duct stones that are found again more than 2 years after biliary lithotripsy. The literature reports a stone recurrence rate of 0-5.8% after laparoscopic common bile duct exploration with one-stage suturing [3-7, 13], which is a reduced stone recurrence rate compared with the 10% recurrence rate of open exploration for biliary stones [14].
The reasons for this may be: 1, the surgical indications for laparoscopic exploration of one-stage suture cases are more stringent; 2, the normal Oddi muscle function is significant in preventing bacteria from entering the bile duct, and after T-tube drainage in the common bile duct, bacteria are prone to enter the bile duct from the T-tube and papillae due to the decrease in normal bile duct pressure, which is even lower than that of the intestine, inducing biliary inflammation and increasing stone recurrence factors; 3, stone recurrence may be related to the choice of suture. It is recommended to choose absorbable sutures. Among 132 cases in our center, one case of recurrence of common bile duct stone was found in an 82-year-old female, 3 years postoperatively, who was found to have recurrence of common bile duct stone by ultrasound examination after an accidental fall with pain in the right side of the chest and abdomen.
IV. Postoperative biliary stricture
Postoperative biliary strictures in laparoscopic common bile duct exploration with one-stage suture cases are not well reported in the literature, Cai et al. reported that 134 patients with one-stage suture did not develop biliary strictures [5], and Yao Jing et al. reported 291 surgical patients in China, of whom 27 cases developed imaging biliary strictures but did not show any symptoms [13]. The appearance of such postoperative cases of imaging strictures may be related to the following factors: 1) laparoscopic suture technique with improper suture spacing; 2) unreasonable selection of sutures, such as the selection of multi-stranded silk; 3) for the choice of choledochotomy method. There were no cases of biliary stricture among 132 cases in the authors’ unit. For the mode of common bile duct incision, our center always used a longitudinal laparoscopic incision knife with a length of 1-37.5 px to avoid possible electrical damage caused by using an electric knife; sutures were taken as 4-0 or 5-0 antimicrobial microdisplaced continuous sutures (122 cases) or “8” sutures (10 cases). We believe that there is no difference between the effect of continuous suture and “8” suture, but the suture is convenient and the suture time is shortened.
Laparoscopic common bile duct exploration with one-stage suturing can solve gallbladder stones and extrahepatic bile duct stones at one time, and there is no need to keep T-tube after surgery. In comparison, it has the advantages of minimally invasive, does not affect the function of duodenal papilla, rapid patient recovery, short hospital stay, and no need for re-imaging and extubation. A recent meta-analysis also concluded that laparoscopic bile duct extraction with one-stage suturing is safer and more effective than laparoscopic exploration for T-tube drainage [15-16].
However, not all patients with gallbladder stones complicated by common bile duct stones are suitable for this surgical procedure, which is still used in selective cases. The indications for surgery in our center are (1) primary or secondary common bile duct stones clearly identified by preoperative MRCP or CT, without intrahepatic bile duct stones and less than 5 stones in the bile duct; (2) common bile duct diameter ≥0. 8 cm , without stenosis in the lower end of the common bile duct; (3) (3) no obvious acute inflammatory edema changes in the common bile duct wall; (4) the stones in the common bile duct can be removed and the number of stones taken is consistent with the number of stones in the bile duct with preoperative MRCP; (5) good opening and closing of the duodenal papilla and distal patency observed by choledochoscopy. Strictly mastering the surgical indications for laparoscopic common bile duct exploration bile duct one-stage suturing is a guarantee to avoid surgical complications. In addition, careful preoperative imaging evaluation, skilled intraoperative choledochoscopic operation and precise suturing can reduce the occurrence of surgical complications.
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