Page 7 - World Journal of Laparoscopic Surgery

Laparoscopic Common Bile Duct Exploration
(LCBDE) by choledochotomy and primary duct closure using the laparoscopic surgery; in the other three centers, the management
three-port technique vs the conventional laparoscopic approach was performed by laparoscopic general surgeons. This material
(CLA) between January 2013 and December 2017 in five centers was presented at SAGES meeting, Baltimore, 2019 (Abstract id
of Bogota, Colombia. There were 197 consecutive patients with 94039).
failed endoscopic retrograde cholangiopancreatography (ERCP) in
gallbladder and CBD stones. The choice of the use of three ports IndIcAtIons
or the conventional technique was decided by the surgeon based Inclusion Criteria
on their expertise, skills, and intraoperative findings. Data from
104 patients with failed ERCP who underwent novel three-port Our series involves patients over 18 years of age with CBD stones
approach were compared with 93 patients of the conventional taken to cholecystectomy, choledochotomy, and CBD primary
multiport laparoscopic approach. The evaluated variables were closure by the laparoscopic technique following failed ERCP.
demographic, clinical, intraoperative, and postoperative outcomes Exclusion Criteria
(Table 1). Patients with CBD diameter <6 mm, acute cholangitis, severe acute
Data were retrospectively collected and entered in the Excel biliary pancreatitis, previous history of cholecystectomy, CBD
database. These included demographic information, patient malignancy, severe adhesive bowel syndrome due to prior open
medical history (with particular attention to any biliary pathology), procedures, and those unwilling or unfit to undergo laparoscopic
symptoms and form of presentation, age, sex, obstructive jaundice, surgery were excluded.
American Society of Anesthesiologists (ASA) physical status
classification system (ASAPS), surgery time, bleeding, bile leaks, surgIcAl technIque
complications, number of CBD stones removed, use of the T tube,
conversion rates to laparotomy, oral feeding time, intensive care Patient Preparation
unit (ICU) admission, hospital stay time, the need for reintervention, All the patients were prepared for LC and CBD exploration using
postoperative strictures, stone recurrence, and mortality. choledochotomy and primary closure just as they would be for an
Follow-up data included hospital readmissions, diagnosis of open operation. Patients and their families were informed of the
residual stones, or new CBD procedures. Patient follow-up was surgical risks, the possible need for additional trocars, conversion
carried out in the outpatient clinic for the first year, after which all to open surgery, and mortality.
data available in the patient medical records were reviewed; visits to
the emergency or gastroenterology departments or any procedure Equipment and Room Set-up
for biliary disorders were investigated. Under general anesthesia, the patient was placed in the supine
All patients had preoperative hepatobiliary ultrasound as position with both arms tucked along their sides and pneumatic
first diagnosis image, then underwent to magnetic resonance stocking, also with the legs spread wide open. The patients were
cholangiopancreatography (MRCP) to confirm the diagnosis; securely strapped to the surgical bed to facilitate maximum tilting
Patients who had a CBD stone confirmation and failed ERCP were and lateral rotation of the surgical table. All patients received
deemed candidates for a surgical CBD stone removal. prophylactic antibiotics according to the latest clinical practice WHO
Patient consent for laparoscopic surgery and research was guidelines for prevention of surgical site infection (SSI). All of the
obtained before the procedure was started. The study protocol procedures were performed in the French position, the first surgical
was approved by our institution’s ethics committee. The protocol assistant stood at the surgeon’s right and the second assistant to the
was implemented in accordance with provisions of the Declaration left. The scrub nurse stood to the right of the first surgical assistant.
of Helsinki and Good Clinical Practice guidelines. Two of the
surgical centers, where the three-port technique was used, had Laparoscopic Cholecystectomy and CBD Exploration
hepatobiliary surgeons with more than 5-year experience on Using Choledochotomy and Primary Closure by Three-
port Technique
Table 1: Comparative sociodemographic variables, between three-port Under general anesthesia, an open Hasson’s technique was made
and conventional laparoscopic approach (CLA) for the placement of a 12-mm umbilical port and creation of
Variables Three-port (n = 104) CLA = 93 pneumoperitoneum applying a 14 mm Hg intra-abdominal pressure
Sociodemographic characteristics to allow the insertion of a 30° laparoscope. Two additional ports
Age (years) (min–max) 47 (47–91) 52 (52–59) were placed under direct vision, a 5-mm port in the right flank and
Sex a 12-mm port in the left paramedial area (Fig. 1).
Using a single Prolene 2-0 (Ethicon, Inc., Cincinnati, OH, USA)
Male (%) 72 66 suture, the gallbladder was elevated from the fundus and held
Female (%) 28 34 against the abdominal wall in the right upper quadrant in order
Patients with comorbidities (%) 32 27 to expose Calot’s triangle (Fig. 2). Using a laparoscopic dissector
Obese patients (n) and hook, the triangle of Calot was dissected revealing the critical
BMI > 30 17 6 view. Once the porta hepatis and the inferior hepatic surface
ASAPS were exposed, dissection of the common hepatic and CBD was
I (%) 35 59 performed taking care not to devascularize the CBD.
A vertical anterior 10–20 mm choledochotomy was performed.
II (%) 48 31 The CBD stones were directly extracted using a laparoscopic
III (%) 17 10 dissector followed by proximal and distal bile duct lavage with a
Obstructive jaundice (%) 86 98 Nelaton tube size 16–20 fr. and 20–50 cc of normal saline solution
Bile duct caliber (mm) 11 (10–13) 13 (10–15) until clear fluid returned (Fig. 3). The last step of the proximal and

World Journal of Laparoscopic Surgery, Volume 13 Issue 1 (January–April 2020) 5