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OBJECTIVE: To compare the safety and feasibility of T-tube drainage and primary suture after laparoscopy combined with choledochoscopy in the treatment of secondary choledocholithiasis. METHODS: The clinical data of patients who underwent laparoscopic choledochoscopy combined with choledochoscopic common bile duct exploration (LCBDE) for secondary choledocholithiasis from June 2015 to June 2020 were analyzed retrospectively. According to the different treatment method of common bile duct (CBD) incision, the patients were divided into a T-tube drainage group and a primary suture group. The preoperative clinical characteristics, results of preoperative liver function tests (LFTs), LFTs on the first day after the operation and the fourth day after the operation, operation time, intraoperative bleeding, postoperative complications, and times of postoperative hospital stay were compared between the two groups. RESULTS: There was no significant difference in preoperative clinical data, preoperative LFTs, and postoperative complications between the two groups (P > .05). However, primary suture demonstrated significant advantages (P

Objective: The effectiveness and feasibility of the primary closure after laparoscopic common bile duct exploration (LCBDE) have been well demonstrated, however, the incidence of postoperative bile...

Clip migration into the common bile duct (CBD) is a rare complication of laparoscopic biliary surgery. We report a case of Hem-o-lok clip migration-induced CBD stone in a 66-year-old man who underwent laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) 4 years ago. The patient visited the emergency room for upper abdominal pain. CT scan revealed increased CBD diameter and multiple CBD stones. We performed endoscopic retrograde cholangiopancreatography for CBD stone extraction. Cholangiography revealed multiple suspected filling defects in the CBD; stones and unknown foreign body were removed using Basket. The foreign body found in the duodenum was a Hem-o-lok clip. When epigastric pain develops in a patient who has undergone LC and LCBDE, it is possible that biliary stone occurs due to clip migration.

Background: Common bile duct exploration (CBDE) is performed uncommonly. Issues surrounding its uptake in the laparoscopic era include perceived difficulty and lack of training. We aim to determine the success of CBDE performed by "specialist" and "nonspecialist" common bile duct (CBD) surgeons to determine whether there is a substantial difference in success and safety. Methods: A 10-year retrospective audit was performed of patients undergoing CBD exploration for choledocholithiasis. Northern Health maintains an on-call available "specialist" CBD surgeon roster to aid with CBDE. Results: Five hundred fifty-one patients were identified, of which 489/551 (88.7%) patients had stones successfully cleared. Specialists had a higher success rate (90.8% versus 82.6%, P = .008), associated with a longer surgical time. Method (transcystic or transductal), approach (laparoscopic or open), and indication for operation were similar between groups. There was no significant difference in complications. To be confident of a surgeon having an 80% success rate, 70 procedures over 10 years were required, however, an "in-control" 50% success rate may only require 1 procedure per year. Conclusion: While specialist CBDE surgeons have improved success rates, nonspecialist general surgeons also have a good and comparable success rate with an equivalent complication rate. With realistic annual targets, nonspecialist CBD surgeons should be encouraged to perform CBDE in centers without specialist support.

The purpose of this study was to investigate the recurrence factors of choledocholithiasis after common bile duct (CBD) exploration.From January 2000 to December 2018, we retrospectively reviewed 253 patients who underwent CBD exploration surgery. We excluded 100 cases who had residual stone, combined major surgery, or follow-up loss after surgery. Total of 153 patients were included, and we investigated the recurrence factors of choledocholithiasis. Various variables such as patients' demographics, gallstones, preoperative endoscopic treatment, and laboratory data were analyzed to find factors related to recurrent choledocholithiasis.The median follow-up period was 20.6 months (range 4.7-219 months), and 27 patients (17.6%) had experienced recurrent choledocholithiasis. Univariate analysis showed that the following variables were associated with recurrence of choledocholithiasis; preoperative leukocytosis (white blood cell ≥ 11,000/µL), open procedure, T tube insertion, long hospital duration, and long operation time. Logistic regression multivariate analysis identified preoperative leukocytosis (odds ratio [OR], 3.43; 95% confidence interval [CI], 1.21-9.73;Because of delayed recurrence of choledocholithiasis, it is recommended to continue follow-up of patients after CBD exploration surgery. Laparoscopic surgery was observed to be associated with a reduction in recurrence. The preoperative leukocytosis and clinical conditions in which open surgery is performed could be associated with recurrence of choledocholithiasis. However, further study is necessary to validate the result.

Background The transcystic approach to laparoscopic common bile duct exploration has gained popularity for the single-stage management of choledocholithiasis with concomitant gallstones. Our team previously described the use of a porcine aorta segment to simulate the common bile duct during laparoscopic skill training. Methods With the advent of the transcystic approach as a contender for the first-line technique of accessing the common bile duct, we present an evolution of the laparoscopic training model using a Porcine Aorta-Renal Artery (PARA) specimen to simulate the structural integrity, dimensions and spatial distribution of both the human cystic and common bile ducts. Results This training model allows the use of a choledochoscope for transcystic exploration of the biliary tree. It combines fidelity and reproducibility required for a simulated training model to offer experience in laparoscopic transcystic common bile duct exploration. Validation of the model was demonstrated by 21 surgeons who completed a questionnaire after performing the simulated procedure. In all sections assessing reliability, face validity and content validity of the model, mean rating scores were between 4 and 5 out of five (good or excellent). Conclusions We present the evolution of an established training model for laparoscopic common bile duct exploration which focusses the attention on the transcystic approach to the common bile duct and the use of lithotripsy techniques. The need for such a model reflects the shift in the current practice of the laparoendoscopic management of choledocholithiasis with concomitant gallstones from transductal to transcystic approach.

Objective The primary aim of this study was to describe the service model of one session management, with a limited role for preoperative endoscopic clearance. The secondary aim was to review the outcomes and long term follow up in comparison to available studies on LCBDE. Background The laparoscopic era brought about a decline in the conventional surgical management of common bile duct stones (CBDS). Preoperative endoscopic removal became the primary method of managing choledocholithiasis. Although laparoscopic common bile duct exploration (LCBDE) deals with gallstones and ductal stones in one session, the limited availability of such an advanced procedure perpetuated the reliance on the endoscopic approach. Methods Prospective data was entered into a single surgeon's database containing 5739 laparoscopic cholecystectomy over 28 years and analysed. Results 1318 consecutive LCBDE were included (23% of the series). Intraoperative cholangiography (IOC) was performed in 1292 (98.0%). The median age was 60 years, male to female ratio 1:2 and 75% were emergency admissions. Most patients (43.4%) presented with jaundice. 66% had transcystic explorations and one third through a choledochotomy with 2.1% retained stones, 1.2% conversion, 18.7% morbidity and 0.2% mortality. Postoperative ERCPs were needed 3.1%. Recurrent stones occurred in 3%. Conclusion One stage LCBDE is a safe and cost effective treatment where the expertise and equipment are available. Endoscopic treatment has a role for specific indications but remains the first line treatment in most units. This study demonstrates that establishing specialist services through training and logistic support can optimise the outcomes of managing CBDS.

Common bile duct (CBD) stones are reported in ~ 15% of patients who undergo laparoscopic cholecystectomy for symptomatic gallstones. Prior to lithotripsy techniques, transcystic laparoscopic common bile duct exploration (LCBDE) was limited to smaller CBD stones. The addition of lithotripsy to LCBDE increases cost, operative time and staffing requirements. Predicting which patients might require lithotripsy would be useful in operative planning. The primary aim was to investigate clinical variables for predicting lithotripsy assistance during transcystic bile duct exploration by laparoendoscopy (PRE-LABEL). Secondary aims were to develop and validate a predictive scoring tool. A retrospective review of a prospectively collected database of consecutive patients who underwent transcystic LCBDE at a single centre in the UK was performed to investigate clinical variables for PRE-LABEL and develop a scoring tool (ABCdE score: age, bilirubin, CBD diameter, ERCP). Binary logistic regression was used to investigate which independent variables (predictors) were associated with lithotripsy assistance during transcystic LCBDE. The ABCdE score was applied to both UK and Spain patient cohorts to determine its sensitivity, specificity and accuracy. From 8 pre-operative clinical variables analysed, age ≤ 40 years, bilirubin > two-times upper limit of normal, CBD diameter ≥ 10 mm and ERCP failure of stone extraction were independent predictors of requiring lithotripsy during transcystic LCBDE and formed the ABCdE score. The hazard ratios were 2.87, 3.79, 2.78 and 10.06, respectively. An ABCdE score ≥ 2 resulted in 71% sensitivity, 81% specificity and 79% accuracy in predicting lithotripsy during LCBDE (UK cohort). Validation using a contemporary cohort from Spain yielded similar sensitivity, specificity and accuracy. This study represents the only study to date reporting independent predictors of requiring lithotripsy assistance during transcystic LCBDE. ABCdE score ≥ 2 can highlight patients that may require lithotripsy in order to avoid failure of transcystic LCBDE and therefore avoid choledochotomy or post-operative ERCP.

IntroductionEndoscopic and open surgical interventions are widely implemented as the standard practice in common bile duct exploration. However, the laparoscopic approach has been also reported to have comparative/superior outcomes in this concept. This has created an ongoing debate about the ideal approach to adopt in practice.MethodsA systematic review of the published evidence over the last decade that has looked into the outcomes of laparoscopic exploration of the common bile duct through transductal and transcystic approaches.ResultsOur systematic review included 36 relevant papers. The majority were based on nonrandomized protocols conducted in single centers with high expertise. The data analysis showed that laparoscopic common bile duct exploration through both approaches was successful in more than 84% of the patients, with an average length of hospital stay of 5.6 days. Conversion to open surgery was reported in 5%-8% of the patients, and the bile leak rates from the more recent studies was 0%-12%, with mortality figures of 0%-1.3%. The outcomes were statistically in favor of the transcystic route when compared to the transductal route from the viewpoints of bile leak rates, mean operative time, duration of hospital stay and morbidity.ConclusionIn experienced hands, both laparoscopic approaches in common bile duct exploration are safe in patients who are clinically fit to have this intervention. It is associated with a statistically significant lower overall morbidity and shorter duration of hospital stay when compared to open surgery. Relevant up-to-date high-quality randomized trials are unavailable.

Concomitant gallstones and common bile duct stones (CBDS) is a relatively frequent presentation. The optimal treatment remains controversial and the debate persists between two strategies. The one-stage approach: laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LCBDE) has been shown to be equally safe and more cost-effective than the more traditional two-stage approach: endoscopic retrograde cholangiography followed by laparoscopic cholecystectomy (ERCP + LC). However, many surgeons worldwide still prefer the two-stage procedure. This survey evaluated contemporary management of CBDS in Spain and assessed the impact of surgeon and hospital factors on provision of LCBDE. A 25-item, web-based anonymous survey was sent to general surgeons members of the Spanish Surgeons Association. Descriptive statistics were applied to summarize results. Responses from 305 surgeons across 173 Spanish hospitals were analyzed. ERCP is the initial approach for preoperatively suspected CBDS for 86% of surgeons. LCBDE is the preferred method for only 11% of surgeons and only 11% treat more than 10 cases per year. For CBDS discovered intraoperatively, 59% of respondents attempt extraction while 32% defer to a postoperative ERCP. The main reasons cited for not performing LCBDE were lack of equipment, training and timely availability of an ERCP proceduralist. Despite these barriers, most surgeons (84%) responded that LCBDE should be implemented in their departments. ERCP was the preferred approach for CBDS for the majority of respondents. There remains limited use of LCBDE despite many surgeons indicating it should be implemented. Focused planning and resourcing of both training and operational demands are required to facilitate adoption of LCBDE as option for patients.

Laparoscopic common bile duct exploration (LCBDE) is the first choice of treatment for large common bile duct (CBD) stones. Recently, single-operator cholangioscopy (SpyGlass system) has been introduced widely in referral and large medical centers. Several studies have reported favorable results for treatment of large CBD stones guided by SpyGlass. We evaluated the clinical efficacy and safety of SpyGlass-guided laser lithotripsy LCBDE for treatment of large CBD stones. From August 2015 to August 2018, 157 patients with large bile duct stones who met the inclusion criteria were randomly divided into two groups: SpyGlass-guided laser lithotripsy (Group A) and LCBDE (Group B). The efficacy and complications were compared between the groups. Although the first-session stone removal rate in Group A was significantly lower than that in Group B, Group A was not inferior to Group B in terms of total stone removal rate. Compared with Group B, Group A had shorter hospital stay and enhanced recovery. The short-term complication rates were also similar between the two groups. The clinical efficacy of SpyGlass-guided laser lithotripsy for the treatment of large CBD stones is not inferior to that of LCBDE, and it is less invasive. SpyGlass-guided laser lithotripsy is an important option for treatment of large CBD stones.

Robotic cholecystectomy is safe and feasible approach and can be combined with common bile duct exploration to address complicated pathology in a single setting. This article summarizes reported outcomes after robotic biliary surgery. A technical overview of robotic multiport and single port cholecystectomy is provided. Last, the approach to benign bile duct disease during robotic cholecystectomy, including reconstruction of the biliary tree, is described.

Choledocholithiasis is a common presentation of symptomatic cholelithiasis that can result in biliary obstruction, cholangitis, and pancreatitis. A systematic English literature search was conducted in PubMed to determine the appropriate management strategies for choledocholithiasis. The following clinical spotlight review is meant to critically review the available evidence and provide recommendations for the work-up, investigations as well as the endoscopic, surgical and percutaneous techniques in the management of choledocholithiasis.

The surgical strategy to resolve the underlying biliary pathology in patients with acute gallstone pancreatitis (AGP) remains controversial. The aim of this study was to evaluate the safety and effectiveness of early laparoscopic cholecystectomy (ELC) in patients with mild AGP. A retrospective cohort of consecutive patients diagnosed with mild AGP according to the Atlanta Guidelines from January 2009 to July 2019 was selected. Patients were assigned to surgery on the first available surgical shift, 48 h after the symptoms onset. Univariate analysis was performed to determine the association between AGP and grades of Balthazar (A, B and C) with time to surgery, days of hospitalization and postoperative complications. From 239 patients evaluated, 238 (99.58%) were operated by laparoscopic approach. Intraoperative cholangiogram was performed routinely. Choledocholithiasis, if present, was successfully treated by laparoscopic common bile duct exploration in all cases. A significant association was found between Balthazar grades and time to surgery (median of 3 days, p = 0.003), with length hospitalization and from surgery to discharge, with median of 4 days (p = 0.0001) and 2 days (p = 0.003), respectively. Mild postoperative complications (CD I/II) were observed in 22/239 patients (9.2%). This represents 2% of patients with grade A of Balthazar, 9% of grade B and 14% of grade C (p = 0.016). We observed no severe complications or mortality. ELC with routine intraoperative cholangiogram, performed on the first available surgical shift 48 h after the symptoms of pancreatitis onset, is a viable, effective and safe strategy for the resolution of mild AGP and its underlying biliary pathology in a single procedure.

Background: Laparoscopic surgery has changed many ways in which we as surgeons manage patients, offering better results, quicker recovery, and fewer complications using minimally invasive techniques, especially in common bile duct (CBD) surgery. Not only can laparoscopic techniques be applied to programed surgery but also emergencies and those following failed endoscopic retrograde cholangiopancreatography (ERCP). Objectives and aims: Describe and compare clinical and surgical results of the laparoscopic CBD exploration with primary closure using a 3-port vs multiport approach. Materials and methods: We present a multicentric comparative study of 197 consecutive patients who underwent a laparoscopic gallbladder removal along with CBD exploration with primary closure following failed (ERCP to extract CBD stones; 104 patients were managed by three-port vs 93 multiport laparoscopic surgery in five centers of Bogotá, Colombia, between 2013 and 2017 with follow-up of 1 year. Results: A total of 197 patients were taken to laparoscopic gallbladder removal along with CBD exploration with primary closure, 104 patients via three-port technique and 93 patients via multiport. All (100%) the patients had previously failed ERCP. The average surgical time on the three-port approach was 106 minutes vs 123 minutes on multiport. Only in the multiport technique we had an average conversion of 2%. Mean hospital stay of 2.5 days, less for the three-port approach vs multiport in 5–7 days. There was a need of reintervention in 1% of the patients who underwent three-port exploration. Conclusion: Postoperative pain, use of an additional port, complication rates, operation time, and cost of the three-port technique were similar to those of the conventional approach. Large randomized controlled trials are needed to examine the true benefits of the three-port technique.

Introduction: One of the safe & feasible methods for the management of extra-hepatic bile duct calculi is laparoscopic bile duct exploration. Around 10-15% of the subjects who have surgery due to gallstone disease have choledocholithiasis associated with it. A standard procedure to prevent bile escape from the choledochotomy site is conventionally postoperative T-tube drainage following common bile duct exploration. Aims & Objectives: Comparative study of laproscopic common bile duct exploration using stent drainage versus t- tube drainage. Material & Methods: The study involved a total of 46 subjects with choledocholithiasis, who were categoryed in 2 categorys. Category I as a drainage category of stents and Category 2 as a drainage category of T-tubes. The subjects in both classes underwent LCBDE surgery. Of the 46 subjects operated, 23 were in category I (stent drainage category) and 23 were in category 2 (T-tube drainage category). Results: 23 subjects were categoryed in the stent drainage and T-tube drainage categories, respectively. In both classes, no perioperative or postoperative mortality was reported. Subjects had hypertension in stent drainage category 4 (17.39 percent) and 5 (21.73 percent) suffered from diabetes as a comorbid disease, while 2 (8.69 percent) subjects had jaundice. Four (17.39 percent) subjects with diabetes and three (13.04 percent) subjects with jaundice were found in T-tube drainage category 3 (13.04 percent) with hypertension. In both classes, no statistically significant difference was found. In terms of organisational results and outcomes, statistically significant variations were found in both categorys (Table 3). Mean operating time was 103± 22.4 in category I while 127±32.7 (P value < 0.005) in category II. In the Stent Drainage Category, blood loss during procedure was 22±3.7 ml, while in the T-tube drainage category it was 38±5.1 (P value < 0.005). Conclusion. After laparoscopic choledochotomy, primary closure of the bile duct with spontaneously reversible biliary stent placement is a viable and practicable process. With spontaneously removable biliary stents, less surgery time, less bleeding and less intestinal complications have been observed. Keywords: stent drainage, T- tube drainage, choledochotomy

Aim Common bile duct (CBD) stones are the most common cause of obstructive jaundice. Laparoscopic exploration of the CBD with laparoscopic cholecystectomy has been preferred to endoscopic treatment, as a single-stage modality of treatment for CBD stones. This procedure was started in a District General Hospital in May 2019 using the standard port sites and Ambu® aScope™ 2 single-use flexible scope. Methods Retrospective analysis of outcome of all laparoscopic CBD explorations done in a District General Hospital between May 2019 and September 2020. Results A total of ten laparoscopic CBD explorations were carried out during the identified period, the main indications were young patients (40%), referral by gastroenterologist (40%) and failed endoscopic retrograde cholangiopancreatography (ERCP) (20%). The mean age (±SD) was 54.7 (± 19.2) and 70% of patients were females. Two thirds of the operations were done in emergency setting, with choledochotomy approach being used in 60% of cases and primary closure in all cases. The average length of stay (±SD) after the operation was 3.1 (±1.9). Only one patient developed a haemoserous collection that required a laparoscopic washout, none of the patients required readmission. Conclusion Laparoscopic CBD exploration can be performed safely in a district general hospital, the disposable Ambu® aScope™ 2 is safe, feasible and cost-effective substitute to the reusable choledochoscope. Provision of this laparoscopic CBD exploration at district general hospital level is more convenient to patients and can reduce referrals to regional hepatobiliary units, and therefore provide a good training opportunity for surgical registrars in this setting.

Background and objectives Laparoscopic cholecystectomy with common bile duct exploration (LC with LCBDE) remains the preferred technique for difficult common bile duct stone (CBDS) removal. The chopstick method uses commonly available instruments and may be cost-saving compared to other techniques. We studied the outcome of LCBDE using the chopstick technique to determine if it could be considered a first-choice method. Methods Data from all patients that underwent LCBDE from January 1, 2012 to April 30, 2019 were retrospectively analyzed. A standard 4-port incision and CBDS permitted extraction with two laparoscopic instruments by chopstick technique via vertical choledochotomy. Demographic data, stone clearance rate, surgical outcomes, complications, and other associated factors were evaluated. Results Thirty-two patients underwent LCBDE. The mean number of preoperative endoscopic retrograde cholangiopancreatography (ERCP) sessions was 2.4. In 65.5% of cases, the CBDS was completely removed by the chopstick technique, while 96.9% of stones were removed after using additional tools. The need for additional instruments was associated with increased age, increased numbers of stones, longer period from the latest ERCP session, and previous upper abdominal surgery. The conversion rate to open surgery was 28.1% and was significantly associated with a history of upper abdominal surgery. Conclusion The chopstick technique is a good alternative and could be considered as a first-line technique in LCBDE to remove the CBDS in cases with 1 to 2 large suprapancreatic CBDS due to instrument availability, cost-effectiveness, and comparable surgical outcomes.

Background: Common bile duct stones (CBDS) are treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) or with the single-stage lap...

Background Recurrence of common bile duct stone (CBDS) is not common after laparoscopic common bile duct exploration (LCBDE). This study aimed to investigate the risk factors of recurrence of CBDS after LCBDE. Methods Patients who underwent LCBDE between January 2001 and December 2018 in four teaching hospitals of The Catholic University of Korea were included. The operation, fluoroscopy, and endoscopic retrograde cholangiopancreatography records were investigated retrospectively. The primary outcome of this study was the independent risk factors for recurrence of CBDS. Results A total of 230 patients were included in this study. Thirty-one patients had recurrence of CBDS. In univariate analysis, CBDS size (>9 mm) (P = 0.003), multiple stones (≥2) (P = 0.031), stone size (≥1.5 cm) (P = 0.041), CBD diameter (≥12 mm) (P = 0.005), CBD dilatation (≥10 mm) (P = 0.02), prior history of laparoscopic cholecystectomy (P = 0.002) were associated with recurrence. After multivariable logistic regression, CBDS size (>9 mm) (OR 4.67, 95% CI 1.35-16.18, P = 0.011), CBD dilatation (≥10 mm) (OR 5.66, 95% CI 1.47-21.82, P = 0.012), and prior history of laparoscopic cholecystectomy (AOR 3. 90, 95% CI 1.34-11.37, P = 0.013) were associated with recurrence. Conclusions Stone size >9 mm, CBD diameter ≥10 mm, and prior history of laparoscopic cholecystectomy were risk factors for recurrence of CBDS after LCBDE.

Laparoscopic cholecystectomy (LC) is the criterion standard for treating patients with symptomatic gallstone disease; however, the optimal technique for extracting common bile duct stones remains unclear. Recent studies have noted improved outcomes with single-stage techniques, such as intraoperative endoscopic retrograde cholangiopancreatography (iERCP) and laparoscopic common bile duct exploration (LCBDE); however only few studies have directly compared those two single-stage techniques. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we retrospectively analyzed the postoperative outcomes of all patients who underwent single-stage LC for choledocholithiasis from 2005 to 2017. Using Current Procedural Terminology (CPT) codes, as well as International Classification of Diseases, Ninth Revision (ICD-9) and 10th Revision (ICD-10) codes, we stratified patients into two cohorts: those who underwent iERCP and LCBDE. Applying univariate techniques, we evaluated baseline characteristics and postoperative outcomes for both cohorts. Our primary outcomes of interest were 30-day morbidity and 30-day mortality; our secondary outcomes included rates of reoperation, readmission, operative time, and hospital length of stay. Of the 1814 single-stage LC patients during our 13-year study period, 1185 (65.3%) underwent LCBDE; 629 (34.6%) underwent iERCP. Our univariate analysis showed that the two cohorts were homogeneous in terms of baseline characteristics, including demographics, preoperative comorbidities, laboratory values, and American Society of Anesthesiologists (ASA) scores. 30-day postoperative morbidity (including infectious and noninfectious complications) and overall mortality between groups were low and comparable. The mean operative time was slightly longer with LCBDE (125.1 ± 62.0 min) than iERCP (113.5 ± 65.2 min; P

Background: Overall, 5% to 15% of patients undergoing cholecystectomy for cholelithiasis have concomitant bile duct stones, and the incidence of choledocholithiasis increases with age. Endoscopic Retrograde Cholangiopancreatography (ERCP) with consequent Laparoscopic Cholecystectomy (LC) has been the favored approach for the treatment of choledo-cholithiasis for quite a long time; however in the course of recent years, Laparoscopic Common Bile Duct Exploration (LCBDE) has been offered to patients with suspected choledo-cholithiasis.Aim of Study: The aim of this work is to compare the efficacy, safety, and the surgical outcomes of LCBDE with ERCP followed by laparoscopic cholecystectomy and deter-mine the most appropriate approach for patients with choledo-cholithiasis.Patients and Methods: A prospective randomized clinical study was carried out from March 2017 to September 2018. It included 50 patients with cholecysto-choledocholithiasis who were divided into two groups: Group A (25 patients) included patients who underwent laparoscopic transcystic common bile duct exploration and stone extraction with LC in one stage, and Group B (25 patients) included patients who underwent endoscopic retrograde cholangiopancreatography for CBD stone extraction followed by LC in two stages. The Common Bile Duct (CBD) stone clearance rate, post-operative bile leakage, post-operative morbidity, mortality, overall hospital stay, and patient satisfaction were analyzed.Results: LCBDE and ERCP+LC were similar in terms of clearance rate, operative time postoperative complications, retained CBD stones, and postoperative length of stay, but there was a significant difference in number of procedures and patient satisfaction.Conclusion: Although both approaches have equivalent success rates, LCBDE is better in terms of fewer procedures, and better satisfaction compared with ERCP + LC. Our study suggests that one-stage management is the treatment of choice for patients with cholecystocholedocholithiasis.

Consensus guidelines recommend patients with symptomatic cholelithiasis and suspected choledocholithiasis have common bile duct exploration (CBDE) at the time of cholecystectomy to prevent downstream problems. Despite superiority of single-stage cholecystectomy with CBDE, 2-stage precholecystectomy/postcholecystectomy with endoscopic clearance of the duct is commonly practiced. This is related to inadequate training in minimally invasive techniques, lack of technical support for efficient and safe CBDE, and surgeons' inexperience with complex biliary pathologic condition. This article provides a framework for evaluating and treating patients with CBD pathologic condition with an emphasis on technical aspects of CBDE and preoperative planning and preparation.

The aim of this study is to evaluate the feasibility, safety, advantages and surgical outcomes of laparoscopic bilateral adrenalectomy (LBA) by an anterior transperitoneal approach. From 1994 to 2018, 552 patients underwent laparoscopic adrenalectomy, unilateral in 531 and bilateral in 21 patients (9 females and 12 males). All patients who underwent LBA were approached via a transperitoneal anterior route and form our study population. Indications included: Cushing’s disease (n = 11), pheochromocytoma (n = 6), Conn’s disease (n = 3) and adrenal cysts (n = 1). Mean operative time was 195 ± 86.2 min (range 55–360 min). Conversion was necessary in one case for bleeding. Three patients underwent concurrent laparoscopic cholecystectomy with laparoscopic common bile duct exploration and ductal stone extraction in one. Three postoperative complications occurred in one patient each: subhepatic fluid collection, intestinal ileus and pleural effusion. Mean hospital stay was 6.1 ± 4.7 days (range 2–18 days). In our experience, transperitoneal anterior LBA was feasible and safe. Based on our results, we believe that this approach leads to prompt recognition of anatomical landmarks with early division of the main adrenal vein prior to any gland manipulation, with a low risk of bleeding and without the need to change patient position. Unlike the lateral approach, there is no need to mobilize the spleno-pancreatic complex on the left or the liver on the right. The ability to perform associated intraperitoneal procedures, if required, is an added benefit.

Background It is not clear whether laparoscopic transcystic exploration (LTCE) laparoscopic choledochotomy (LCD) is superior in the management of choledocholithiasis. In this meta-analysis, the success of LTCE versus LCD was evaluated. Methods Cochrane Central Register of Controlled Trials, Web of Science, Trip, PubMed, Ovid and Embase databases were searched systematically for relevant literature up to May 2017. Studies that compared the success rate of LTCE and LCD in patients with choledocholithiasis were included. PRISMA guidelines were followed. Multiple independent reviewers contributed on a cloud-based platform. Random-effects model was used to calculate odds ratios (ORs) or standardized mean differences (MDs) with 95 per cent confidence intervals. An a priori hypothesis was generated based on clinical experience that LTCE is as successful as LCD. Results Of 3533 screened articles, 25 studies comprising 4224 patients were included. LTCE achieved a lower duct clearance rate than LCD (OR 0.38, 95 per cent c.i. 0·24 to 0·59). It was associated with a shorter duration of surgery (MD -0·86, 95 per cent c.i. -0·97 to -0·77), lower bile leak (OR 0·46, 0·23 to 0·93) and shorter hospital stay (MD -0·78, -1·14 to -0·42) than LCD. There was no statistically significant difference in conversion, stricture formation or reintervention rate. Conclusion LCD has a higher rate of successful duct clearance, but is associated with a longer duration of surgery and hospital stay, and a higher bile leak rate.

Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction is a common and preferred choice for gallstone disease. Laparoscopic common bile duct exploration (LCBDE) and laparoscopic cholecystectomy (LC) are being increasingly used for managing choledocholithiasis and cholecystolithiasis. We report a case of a Hem-o-lok clip that was dropped into the common bile duct (CBD) after LC and surgical common bile duct exploration (CBDE). An 84-year-old man presented with right upper quadrant pain and jaundice for 2 months, and chills and hyperpyrexia for 1 day. The patient had received ERCP and surgical CBDE at a local hospital 3 years previously. The patient first received ERCP and endoscopic nasobiliary drainage (ENBD). When laboratory tests were normal, the patient then received LCBDE. During exploration, stones and a Hem-o-lok clip in the CBD were removed. The patient made good progress after LCBDE + T-tube placement and was discharged from hospital. The findings from this case suggest the following: 1) an appropriate therapy method should be considered for certain gallstone diseases, especially for choledocholithiasis and cholecystolithiasis; and 2) a Hem-o-lok clip should be carefully used during laparoscopic or robot-assisted surgery and the Hem-o-lok clip should not be in close proximity to the incision on the CBD.

Objective: To compare the effectiveness and safety of continuous suture and interrupted suture in Laparoscopic Common Bile Duct Exploration (LCBDE) for choledocholithiasis. Materials and Methods: T...

Background T-tube drainage after laparoscopic common bile duct exploration (LCBDE) has been demonstrated to be safe and effective for patients with acute cholangitis caused by common bile duct stones (CBDSs). The outcomes after LCBDE with primary closure in patients with CBDS-related acute cholangitis are unknown. The present study aimed to evaluate the efficacy and safety of LCBDE with primary closure for the management of acute cholangitis caused by CBDSs. Methods Between June 2015 and June 2020, 368 consecutive patients with choledocholithiasis combined with cholecystolithiasis, who underwent laparoscopic cholecystectomy (LC) + LCBDE in our department, were retrospectively reviewed. A total of 193 patients with CBDS-related acute cholangitis underwent LC + LCBDE with primary closure of the CBD (PC group) and 62 patients underwent LC + LCBDE followed by T-tube placement (T-tube group). A total of 113 patients who did not have cholangitis were excluded. The clinical data were compared and analyzed. Results There was no mortality in either group. No significant differences were noted in morbidity, bile leakage rate, retained CBD stones, or readmission rate within 30 days between the two groups. Compared with the T-tube group, the PC group avoided T-tube-related complications and had a shorter operative time (121.12 min vs. 143.37 min) and length of postoperative hospital stay (6.59 days vs. 8.81 days). Moreover, the hospital expenses in the PC group were significantly lower than those in the T-tube group ($4844.47 vs. $5717.22). No biliary stricture occurred during a median follow-up of 18 months in any patient. No significant difference between the two groups was observed in the rate of stone recurrence. Conclusions LCBDE with primary closure is a safe and effective treatment for cholangitis caused by CBDSs. LCBDE with primary closure is not inferior to T-tube drainage for the management of CBDS-related acute cholangitis in suitable patients.

A retrospective study of 4628 patients who underwent laparoscopic cholecystectomies with choledocholithotomy with primary repair of common bile duct , with a mean follow-up of 23.2 months is carried outto evaluate the safety and feasibility of laparoscopic choledocholithotomy via choledochotomy for the treatment of choledocholithiasis in Dishari Health Point Private Limited, a multispeciality hospital in Malda from January 2004 to January 2019. We had to convert to open surgery in 27 patients and could complete the operation laparoscopically in rest 4621 patients. We also did open surgery in 30 patients apart from this. We analyse the results and it was found that Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis.

Background: Laparoscopic common bile duct exploration (LCBDE) is an effective treatment for choledocholithiasis. The aim of this study was to determine the predictive factors associated with conversion during LCBDE and to assess the implications of conversion on the patients' postoperative course. Methods: A retrospective cohort study based on patients undergoing LCBDE between 2000 and 2018 was conducted. Uni- and multivariate regression analyses were performed. Results: A total of 357 patients underwent LCBDE, and the conversion rate was 14.2%. The main reasons for conversion were lithiasis extraction (21; 41%) and difficult dissection (13; 26%). Independent predictors for conversion were increasing levels of serum bilirubin prior to surgery (OR=4.745, 95% CI: 1.390-16.198; p=0.013), and emergency setting (OR=4.144, 95% CI: 1.449-11.846; p=0.008). Age was independently associated with lower odds of conversion (OR=0.979, 95% CI: 0.960-0.999; p=0.036). Conversion had a negative impact on the patients' postoperative course, including severe complication (21.6% vs. 5.2% p

Overlapping surgery or double-booking is a vital yet disputed issue in healthcare field. However, safety of the overlapping surgery during laparoscopic common bile duct exploration (LCBDE) remains unclear. This study aimed to assess the clinical outcomes and safety of overlapping surgery during laparoscopic cholecystectomy and LCBDE for gallbladder and common bile duct stones (CBDS).This study retrospectively reviewed 2736 laparoscopic cholecystectomy and LCBDE surgeries during 2013-2020. One thousand, two hundred eighty patients underwent LCBDE through cystic duct, including 867 receiving overlapping procedures, while 1456 underwent LCBDE through laparoscopic choledochotomy (LC), including 981 who underwent overlapping procedures. Data regarding patient sex, age, body mass index, the American Society of Anesthesiology grade, comorbidities, preoperative liver function test, previous upper abdominal surgery, presence of acute cholecystitis, cholangitis, pancreatitis, or jaundice, common bile duct (CBD) or CBDS diameter, CBDS number, LCBDE operation time, procedure duration, length of stay, stone clearance, CBD closure methods, conversion to open surgery, and complications were collected.Differences in demographics and clinical variables between both groups were not significant, and the unadjusted outcomes were comparable, except for the total procedure duration (transcystic:Overlapping surgery in laparoscopic cholecystectomy and LCBDE was safe at our institution. However, the association of patient outcomes with overlapping laparoscopic cholecystectomy and LCBDE should be further investigated.

The extrahepatic biliary tract includes the right, left, and common hepatic ducts; cystic duct; common bile duct; hepatocystic triangle; and the gallbladder. Anomalous hepatic ducts can be a surgically significant source of bile leakage. Detailed step-by-step technique is presented for laparoscopic (robotic) cholecystectomy, intraoperative cholangiogram, common bile duct exploration, open cholecystectomy, sphincteroplasty, choledochoduodenostomy, choledochocystectomy, and hepaticojejunostomy (Hepp-Couinaud) procedure.

Background The ‘gold standard’ for management of gallstones is laparoscopic cholecystectomy, but there is no consensus for treatment of common bile duct stones. There is insufficient information in the literature on the practice of laparoscopic common bile duct exploration (LCBDE) in cases of endoscopically irretrievable stones. This study presents the technical aspects and results of this approach and comparing it with open common bile duct exploration (OCBDE). Aim To assess the management of the patients with calcular obstructive jaundice after failed endoscopic retrograde cholangiopancreatography with LCBDE in comparison with OCBDE. Patients and methods A prospective randomized study was conducted for 2 years started from 2017 to 2019 in Theodor Bilharz Research Institute. A total of 600 patients with calcular obstructive jaundice underwent endoscopic retrograde cholangiopancreatography, with failure of stone extraction in 50 patients. Of them, 30 patients underwent LCBDE and the other 20 patients underwent OCBDE. Overall, 40 patients were female and the other 10 were male. They ranged in age from 23 to 80 years old, with a mean age of 46.72 years. Results The mean postoperative hospital stay, pain score, and analgesia score were significantly short (P 0.05) but with no statistically significant difference. Conclusion LCBDE considered as a safe, efficient and preferred procedure for CBDE whenever possible.

Across the world, choledocholithiasis is presently treated by a two staged approach of Endoscopic Retrograde Cholangio- Pancreatography (ERCP) followed by Laparoscopic Cholecystectomy (LC); in a vast majority of the situations. Modern day literature abounds with comparative outcomes studies between ERCP and Laparoscopic Common Bile Duct Exploration (LCBDE), as therapeutic modalities for Common Bile Duct (CBD) stones. There are strong arguments both in favour and against both these treatment options, in literature. As per literature, the advantage of LCBDE is that it is a single stage procedure, but requires advanced laparoscopic expertise and a choledochoscope in the setup. The advantage of ERCP is that it is a highly standardised procedure. In expert hands and well equipped setups, it rarely ever fails to deliver. However, ERCP is also a highly operator dependant procedure. Also, in the best of hands, sometimes, local factors such as abnormal anatomy, stone morphology can lead to failures or suboptimal results. As per literature, ERCP to extract CBD stones can fail for various reasons such as failed cannulation, previous Billroth II gastrectomy, large CBD stones, large number of CBD stones etc. The failure in retrieving CBD stones by ERCP is an absolute indication for performing CBDE. Here, authors present a case report of a 73-year-old male with failed ERCP (inspite of two attempts) due to a large, solitary but tightly impacted terminal CBD stone. It hopes to convey the message that in similar situations, LCBDE, tactically using some endoscopy accessories, is a sound backup therapeautic option, inspite of non availability of a choledochoscope in the setup. The novelty of this case was that instead of the standard use of choledochoscope to directly visually confirm the completeness of stone clearance during the LCBDE, intraoperative fluoroscopy has been used effectively for the same; by obtaining good quality proximal and distal occlusion cholangiograms at the end of the procedure.

Laparoscopic common bile duct exploration (LCBDE) is increasingly being used to treat choledocholithiasis. However, few studies have examined the treatment of recurrent common bile duct stones (CBDS) in patients with a history of prior biliary surgery. The current research aimed to compare the outcomes of laparoscopic versus open common bile duct exploration in patients with a history of prior biliary surgery.Between March 2010 and August 2019, 162 patients with recurrent CBDS after prior biliary surgery who underwent surgical management in our institution were enrolled in this study. The demographic, intraoperative and postoperative data were retrospectively analysed.Among these 162 patients, 72 underwent laparoscopic approach (LCBDE group), and 90 underwent open surgery (open common bile duct exploration group). The LCBDE group was associated with significantly lower overall complication rate, incision infection rate and blood loss compared to open common bile duct exploration group (all P 0.05). Moreover, the laparoscopic approach significantly reduced the length of postoperative hospital stay (P 0.05). However, the operative time, stone clearance rate, and stone recurrence rate were not significantly different between the two groups (P 0.05). The conversion rate of the laparoscopic approach was 6.9%.LCBDE is superior to open procedure in terms of blood loss, hospital stay, overall complication and incision infection in patients with a history of prior biliary surgery, and it should be considered as a safe and effective treatment if it is performed by an experienced surgeon.

BACKGROUND Laparoscopic common bile duct exploration (LCBDE) can be performed to treat choledocholithiasis at the time of laparoscopic cholecystectomy. The aim of this study was to identify factors that predict the success of LCBDE. MATERIALS AND METHODS A retrospective audit was performed on patients who underwent LCBDE for the management of choledocholithiasis at Northern Health between 2008 and 2018. RESULTS A total of 513 patients were identified with an overall success rate of 90.8%. Most LCBDE were done through a transcystic approach with the remainder through a choledochotomy. When comparing patients with a successful operation to those that were unsuccessful, univariate analysis demonstrated significant differences in preoperative white cell count and number of duct stones found. Age and elevated nonbilirubin liver function tests were found to be significant factors associated with the failure of LCBDE on multivariate analysis. The likelihood of a failed operation in those with multiple stones was observed to be almost halved compared with patients with single stone although this did not reach significance [odds ratio (OR): 0.53, 95% confidence interval (CI): 0.28-1.01, P=0.055]. Multivariate analysis indicated that unsuccessful procedures (OR: 10.13, 95% CI: 4.34-23.65, P

Introduction: Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct (CBD) exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis.1 L...

Laparoscopic common bile duct exploration (LCBDE) has been recently introduced for management of CBD stone in patients with previous biliary surgery history. The aim of this study was to evaluate the safety and effectiveness of primary closure in patients with previous biliary surgery history compared to T-tube drainage. Eighty patients with previous biliary surgery history including laparoscopic cholecystectomy, open cholecystectomy, or open common bile duct exploration were enrolled in the retrospective study. The patients were divided into 2 groups according to the methods of choledochotomy closure. Group A: patients with primary closure after LCBDE (n = 51); group B: patients with T-tube drainage after LCBDE (n = 29). Group A exhibited a shorter postoperative hospital stay and lower hospitalization expenses compared to group B. There was no significant difference in conversion rate to open surgery, operating time, intraoperative blood loss, bile leakage rate, overall complication rate, and stone recurrence rate between the 2 groups. Biliary stricture was not observed in the 2 groups during the follow-up period. Primary closure following LCBDE is safe and effective for the management of CBD stones in patients with previous biliary surgery history.

Background: The aim of this study is to evaluate complications and costs in patients treated with laparoscopic and open method for common bile duct (CBD) stones. Secondary aim is to compare the eff...

BACKGROUND The purpose of this study was to investigate the effect of a simple laparoscopic common bile duct exploration (LCBDE) simulator and corresponding practicing program on the application of performing LCBDE in a low volume center. METHODS A retrospective review was performed by analyzing data from the electronic medical record for 4118 patients with choledocholithiasis in Changxing County Hospital (Huzhou, Zhejiang, China) between January 2013 and December 2018. From January 2016, we have developed a simple LCBDE-specific simulator and corresponding practicing program in our hospital. The percentage of patients with choledocholithiasis managed by LCBDE before and after the introduction of a simple LCBDE-specific simulator and corresponding practicing program was compared. RESULTS There were 8.9% (367/4118) patients with a diagnosis of choledocholithiasis confirmed by MRCP. Single-stage management with LC+LCBDE was performed in 23.7% (87/367) patients. Among them, 23 cases were performed between January 2013 and December 2015, and 64 cases were performed between January 2016 and December 2018. The introduction of simulator-enhanced practicing program in January 2016 has resulted in an increase in the percentage of performed LCBDE, from 12.9% to 33.9%. In addition, there was an 29.5% reduction in the mean operating time (from 193 min to 136 min) needed for LCBDE with T-tube when compared these two periods. CONCLUSIONS LCBDE simulator can improve the application in a low volume center, and help to increase the utilization of this effective, one stage treatment for choledocholithiasis and reduce the need for costlier ERCP.

Background Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. Methods Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. Results 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. Conclusion Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.

Introduction Primary closure of common bile duct (CBD) after laparoscopic common bile duct exploration (LCBDE) is now becoming the preferred technique for closure of choledochotomy. Primary CBD closure not only circumvents the disadvantages of an external biliary drainage but also adds to the advantage of LCBDE. Here, we describe our experience of primary CBD closure following 355 cases of LCBDE in a single surgical unit at a tertiary care hospital. Materials and methods All patients undergoing LCBDE in a single surgical unit were included in the study. Preoperative and intraoperative parameters including the technique of CBD closure were recorded prospectively. The postoperative recovery, complications, hospital stay, antibiotic usage, and postoperative intervention, if any, were also recorded. Results Three hundred fifty-five LCBDEs were performed from April 2007 to December 2018, and 143 were post-endoscopic retrograde cholangiopancreatography failures. The overall success rate was 91.8%. The mean operative time was 98±26.8 minutes (range, 70 to 250 min). Transient bile leak was seen in 10% of patients and retained stones in 3 patients. Two patients required re-exploration and 2 patients died in the postoperative period. Follow-up ranged from 6 months to 10 years, with a median follow-up of 72 months. No long-term complications such as CBD stricture or recurrent stones were noted. Conclusions Primary closure of CBD after LCBDE is safe and associated with minimal complications and no long-term problems. The routine use of primary CBD closure after LCBDE is recommended based on our experience.

BACKGROUND Primary choledocholithiasis (PC) is a common disease in biliary surgery. The treatment is always challenging due to its high recurrence. A systemic review is undertaken to determine the risk factors for recurrence and provide with the individualized management strategy. METHODS Electronic databases PubMed (Medline), Embase and Cochrane Central Register of Controlled Studies were searched for relevant articles on risk factors for PC recurrence. Its therapeutic intervention was also collected and analysed. RESULTS A total of 36 articles were eligible for inclusion. The recurrent risk factors include abnormalities of biliary anatomy (peripapillary diverticulum), dynamics (choledochal dilation, sharp angulation and stone number), metabolism (advanced age and hypothyroidism) and bacterial infection (Enterobacter and Helicobacter pylori). These factors eventually induce cholestasis and stone formation. At present, there is no guideline and expertise consensus for PC management. The treatment mainly consists of stone retrieval approaches and internal drainage surgeries. The former are minimally invasive methods: endoscopic sphincterotomy (EST), papillary balloon dilation (EPBD) and laparoscopic common bile duct exploration (LCBDE). The latter include choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) with Roux-en-Y reconstruction. By far, the internal drainage surgeries have significantly lower recurrence than stone retrieval approaches. CONCLUSION Abnormal biliary anatomy, dynamics, metabolism and bacterial infection are the risk factors for PC. Both EST/EPBD and LCBDE can be performed as initial treatment. For recurrent PC, CDS is more suitable to the elderly, while Roux-en-Y CJS reserves for young patients or those in good conditions.