(A) Indications
1. Pre-operative ultrasound, CT, MRCP and other imaging examinations suggest widening of the common bile duct (>1cm) and bile duct stones;
2. Preoperative ERCP confirmed bile duct stones but not suitable for EST;
3. Intraoperative cholangiography or laparoscopic ultrasonography to confirm the diagnosis of bile duct stones.
(B) Contraindications
1. Stones in the lower bile duct, stricture or suspected periampullary cancer;
2. Intra- and extra-hepatic bile duct stones with hilar bile duct stenosis;
3. Intra- and extra-hepatic bile duct stones requiring hepatectomy, cholangioplasty or bile-intestinal anastomosis;
4. Extensive adhesions in the abdominal cavity after biliary surgery or multiple upper abdominal surgeries.
(C) Surgical steps
Laparoscopic bile duct exploration usually requires simultaneous removal of the gallbladder, so most of its operations are similar to laparoscopic cholecystectomy. Depending on whether the cystic duct is widened or not, transcystic ductal exploration and common bile duct incisional exploration can be adopted respectively. The former is suitable for bile duct stones with short and thick cystic ducts (diameter >5 mm) and small and few stones in the bile duct; otherwise, the latter is preferred.
1. Transcystic duct choledochotomy
(1) Free out the cystic duct and deal with the cystic artery: firstly, dissect the Calot triangle according to the conventional method, free out the short thick cystic duct and cystic artery, ligate or clamp the proximal end of the cystic artery and the distal end of the cystic duct.
(2) Incision of the cystic duct, placement of a guidewire and dilating balloon catheter: The anterior wall of the cystic duct is incised 5mm away from the common bile duct, and a guidewire and balloon catheter are placed to dilate the duct.
(3) Insertion of fiberoptic choledochoscope or ureteroscope: After removing the dilated balloon catheter, the fiberoptic choledochoscope is inserted into the common bile duct through the choledochal incision with the guidewire, and the lithotomy basket is released and the stones are removed one by one.
(4) Ligation or clamping of the stump of the cystic duct: intraoperative choledochoscopy or cholangiography can be used to ligate or clamp the stump of the cystic duct after confirming that the bile duct stones are cleared and the lower bile duct is free of stenosis.
(5) Removal of the gallbladder: see previous section.
(6) Placement of abdominal drainage tube: a multiport abdominal drainage tube is placed between the foramen ovale and the hepatorenal space.
2. Common bile duct dissection and lithotomy, T-tube drainage
(1) Dissect out the upper part of the common bile duct along the cystic duct: after dealing with the cholecystic artery, free the cystic duct and drain it toward the common bile? duct and ? The anterior lobe of the hepatoduodenal ligament is dissected in the direction of the junction of the common hepatic duct until the blue-green bile duct is clearly revealed.
(2) Dissection of the anterior wall of the common bile duct: If the blood vessels are visible in the anterior wall of the upper segment of the revealed common bile duct, the anterior wall of the bile duct can be lifted off with curved separating forceps for electrocoagulation. After placing a small piece of gauze with a barium sulfate thread in the Winslow hole, the anterior wall of the common bile duct is cut longitudinally or obliquely with curved miniature scissors for about 1 cm.
(3) Fiberoptic choledochoscopy probes the bile duct for stone extraction: upward should be probed to the left and right hepatic ducts, and downward should be probed to the lower bile duct. Stones should be removed with a lithotripsy mesh. If there are more stones in the bile duct, the laparoscopic knuckle grasper can be used first to remove the stones directly, which is more convenient and practical, and then the choledochoscope can be used to remove the stones.
(4) Placement of T-tube and suturing of the bile duct incision: Select the corresponding thick and thin T-tube according to the diameter of the common bile duct, and make a short single-arm T-tube of 5mm in the upper arm and 10mm in the lower arm. Use 4-0 absorbable sutures to first close 1 stitch above the T-tube and 2~3 stitches below the T-tube intermittently. The 1 stitch near the T duct should be sutured into a V-shape, which can effectively prevent bile leakage around the T duct.
(5) Removal of the gallbladder: as described previously. The gallbladder specimen is taken out together with gauze in a bag.
(6) Flush the surgical field and place the abdominal drainage tube: fully flush the surgical field and carefully check for bleeding and bile leakage. Pull out the T-tube through the right midclavicular line poke and inject water under pressure to check whether there is bile leakage around the T-tube. The abdominal drainage tube is sent into the abdominal cavity through the right anterior axillary line poke and placed around the T-tube and the hepatic and renal spaces.
(IV) Intraoperative precautions
Bleeding is mainly caused by inadvertent injury to the variant gallbladder artery, right hepatic artery and hepatic artery. Occasionally, the portal vein variants go before the common bile duct, so if the common bile duct is not carefully dissected along the cystic duct and the possibility of portal vein is not tried by puncture first, once the “common bile duct” is mistaken as portal vein, it will lead to hemorrhage and endanger the patient’s life. In addition, direct puncture of the common bile duct with a sharp knife can easily penetrate the anterior and posterior walls of the common bile duct and even injure the portal vein behind the common bile duct. Improper use of electric hooks and scissors around the dissected bile duct can also damage the surrounding important blood vessels and lead to bleeding.
2. Bile leak The main causes are poor suturing around the T duct, unrecognized treatment after injury to the variant paracolic duct or vagus bile duct, and residual stones or strictures in the lower bile duct.
3. Residual bile duct stones The incidence of residual bile duct stones is higher in acute surgery and when there are more bile duct stones. Choledochoscopic stone extraction is feasible after complete formation of T-duct sinus tracts 6~8 weeks after surgery.
4. Residual stones in the abdominal cavity are mostly due to the multiple and fragile stones, and the failure to place gauze in the hole of Winslow and to put the removed stones into the specimen bag in time. Residual stones in the abdominal cavity can be the main cause of abdominal infection and intestinal adhesions.
5. Visceral injury The peripheral organs that can be easily injured are duodenum, transverse colon, stomach, liver, and diaphragm. The main causes are improper use of the electric knife, inadequate preparation of the intestine, and rough and irregular technical operation.