The role of choledochoscopy in transductal laparoscopic common bile duct exploration

Laparoscopic common bile duct exploration (LCBDE) performed by choledochoscope through the cystic duct or directly through the incision in the common bile duct (CBD) are well established methods for restoring biliary drainage function in patients with choledocholithiasis. Although it plays a crucial role in the transcystic approach, transductal approach can be achieved differently. However, it has restrictions in availability due to its expensiveness. Objective — to report efficacy of transductal LCBDE without laparoscopic choledochoscopy. Materials and methods. This is a prospective study of urgently admitted patients who underwent trans‑ductal LCBDE due to confirmed choledocholithiasis. During laparoscopy, clearance of the CBD was achieved in two ways: by choledochoscopy (group CS+, n = 43) and without it (group CS–, n = 34). The data of patient demographics, comorbidities, operative outcomes, morbidity, mortality and long‑term biliary complications were analysed and compared between the groups. Results. Out of a total of 154 patients with confirmed choledocholithiasis, the trans‑ductal approach of LCBDE was applied to 77 patients. In 43 patients, clearance was done with choledochoscope (group CS+) and in 34 patients without it (group CS–). Gallstone related complications and comorbidities did not differ between the groups. Surgery was done 4 days after admission in both groups. Median duration of the operation was significantly shorter in the group CS–, 93 vs 120 minutes (p = 0.036), without any difference in conversion and complication rates. Clearance rate was markedly high in both groups. Conclusions. Transductal laparoscopic common bile duct exploration without choledochoscopy is a time‑saving, safe and effective way for CBD clearance, without additional equipment.

P-BN59 Danger is there, do we want to know about it? Routine intra operative cholangiography highlights dangerous biliary anatomy for safer cholecystectomy

Background Normal biliary anatomy is uncommon. Different classification for biliary anatomy has been described, with Huang Types A4 & A5 of great interest for laparoscopic cholecystectomy (LC) due to the proximity of aberrant bile duct to Cystic duct (CD). These types of dangerous anatomy might contribute to bile duct injury. This study aims to analyse the prevalence of dangerous biliary anatomy. Methods Prospectively collected data for all patients who underwent laparoscopic cholecystectomy was analysed. All LC were performed by single surgeon or under his direct supervision, between 01/07/2020 and 20/08/2021. Index admission and single session management of cholelithiasis disease with routine Laparoscopic cholecystectomy + intra operative cholangiography (IOC) +/- LCBD exploration were standard practice. Results Laparoscopic cholecystectomy was performed in 137 patients. Mean age was 56y (17-84). 62% were females. 66% of Laparoscopic cholecystectomies were emergency. IOC was performed in 92% of cases. Abnormal biliary anatomy was found in 54% : Huang A1 - 48%, A2 - 29%, A3 - 12%, A4 - 9.7% and A5 - 0.7%. Dangerous anatomy (A4 and A5) was found in 10.5%, 78 % were females. Female with dangerous anatomy were younger than males 49 y, 60y respectively. Nassar difficulty grading for dangerous anatomy was as follows: G2 28%, G3 42% and G3 28% Abnormal cholangiogram was found in 48%, due to filling defect in 58%, no contrast flow into duodenum in 4%, Cystic duct stone in 4%, and short CD in 8%. CBD stones were treated using transcystic approach in 92% of cases. No intra-operative or post operative complications were recorded for patients with dangerous anatomy. Conclusions This study demonstrates that dangerous biliary anatomy, that could lead to bile duct injury is relatively common, occurring in 10.7% of LCs. Routine intra-operative cholangiography highlights these high-risk variations in biliary anatomy and may prevent inadvertent bile duct injury in such cases.

Moy.03Evaluation of the Basket in Catheter Technique for Transcystic Bile Duct Exploration and Suspected Ductal Stones

Aims The ‘Basket-in-catheter’ (BIC) technique facilitates laparoscopic transcystic ductal exploration (LTCE) and increases its success rate, being easier and safer than inserting the basket alone. This study evaluates the benefits in confirmed and suspected ductal stones. Methods Prospective preoperative, operative and postoperative data on consecutive single session ductal explorations was collected over 28 years and analysed. BIC became our default technique for the transcystic approach to confirmed or suspected bile duct stones. Results 741 of 1225 (60.5%) attempted LTCE were performed using retrieval baskets without dilating the cystic duct (CD). BIC was used in 646 (87.2%). Of 386 (52.1%) patients undergoing successful stone retrieval 62.7% had clinical and radiological risk factors for ductal stones and 92.0% had positive intraoperative cholangiography. 355 (47.9%) patients had preoperative or operative risk factors for CBD stones and equivocal cholangiography in 25%. Basket trawling was negative and repeat cholangiography confirmed resolution of abnormalities. Choledochoscopy was utilised in 484/1225 (39.5%), either primarily or when blind trawling failed to extract stones. Retained stones occurred in 7 patients, six requiring ERCP. Bile leakage occurred in 6 patients. There were two open conversions, no biliary injuries and no mortality. Post-operative pancreatitis occurred in 7 and recurrent stones in 8 patients. Conclusions The BIC technique achieves successful LTCE without CD dilatation in 40%, reducing the need for choledochoscopy and choledochotomy. It facilitates safe and speedy CBD trawling when stones are suspected due to preoperative or operative risk factors or equivocal cholangiography and helps surgeons acquire and consolidate ductal exploration skills.

EP.TH.594Is Laparoscopic Common bile duct exploration feasible after failed ERCP?

Aims Concomitant gallstones and common bile duct stones are a common problem with no consensus on the best management approach. Our aim is to review the outcomes of laparoscopic clearance of common bile duct stones after failed ERCP. Methods We retrospectively studied all cases that had a failed ERCP prior to surgery in 200 cases of laparoscopic cholecystectomy with common bile duct exploration performed between 2006 and 2019. Results Twenty-two patients underwent a laparoscopic common bile duct exploration after failed ERCP. Seventeen of these were before 2013. Eleven (50%) of these were after at least one failed attempt at clearance. In 8 patients (32%) the duct was not accessible (failed cannulation) due to a variety of reasons. Nine patients had large and impacted stones, two patients had Mirrizi syndrome with concomitant CBD stones, 2 had multiple stones and one a missed stone discovered intraoperatively. CBD clearance was successful in 19 patients (88%), 8 were completed by a transcystic approach and 14 by a transcholedochal approach. Post-operative length of stay was 12 (±10) days. 1 patient had an unplanned re-admission within 30 days. 1 patient required re-operation for bleeding. 3 patients developed recurrent stones and 1 developed a subsequent stricture. No mortalities were recorded. Conclusions Laparoscopic common bile duct exploration is feasible and safe as a secondary procedure after failed ERCP. New technologies and advancements in surgical techniques will continue to improve success and morbidity.

1282 Evaluation of the Basket in Catheter Technique for Transcystic Bile Duct Exploration and Suspected Ductal Stones

Aim The ‘Basket-in-catheter’ (BIC) technique facilitates laparoscopic transcystic ductal exploration (LTCE) and increases its success rate, being easier and safer than inserting the basket alone. This study evaluates the benefits in confirmed and suspected ductal stones. Method Prospective preoperative, operative and postoperative data on consecutive single session ductal explorations was collected over 28 years and analysed. BIC became our default technique for the transcystic approach to confirmed or suspected bile duct stones. Results 741 of 1225 (60.5%) attempted LTCE were performed using retrieval baskets without dilating the cystic duct (CD). BIC was used in 646 (87.2%). Of 386 (52.1%) patients undergoing successful stone retrieval 62.7% had clinical and radiological risk factors for ductal stones and 92.0% had positive intraoperative cholangiography. 355 (47.9%) patients had preoperative or operative risk factors for CBD stones and equivocal cholangiography in 25%. Basket trawling was negative and repeat cholangiography confirmed resolution of abnormalities. Choledochoscopy was utilised in 484/1225 (39.5%), either primarily or when blind trawling failed to extract stones. Retained stones occurred in 7 patients, six requiring ERCP. Bile leakage occurred in 6 patients. There were two open conversions, no biliary injuries and no mortality. Post-operative pancreatitis occurred in 7 and recurrent stones in 8 patients. Conclusions The BIC technique achieves successful LTCE without CD dilatation in 40%, reducing the need for choledochoscopy and choledochotomy. It facilitates safe and speedy CBD trawling when stones are suspected due to preoperative or operative risk factors or equivocal cholangiography and helps surgeons acquire and consolidate ductal exploration skills.

16 Re-Do of Laparoscopic CBD Exploration Through Cystic Duct Remnant Following Laparoscopic Cholecystectomy; A Case Series

Introduction Common bile duct (CBD) stones are detected in approximately 10-15% of patients with gallstone disease. They can be formed in the absence of gallbladder stones or in patients who underwent previous cholecystectomy. Laparoscopic common bile duct exploration has been documented since 1999, with increasing evidence illustrating the effectiveness of the transcystic approach. There is no review of re-exploration of the CBD, due to retained stones, following laparoscopic cholecystectomy (LC) via this approach. Four cases are presented detailing need for initial intervention, and intra-operative findings. Method Review of four cases in 2020 in Aberdeen Royal Infirmary. Each underwent re-do laparoscopic transcystic common bile duct exploration for retained stone, following previous laparoscopic cholecystectomy. Results Each case had successful stone clearance and resolution of symptoms. Conclusions With increasing laparoscopic technology and surgical skill, re-exploration of the CBD following previous LC due to emergency surgical presentations should be performed. This is feasible and safe. We recommend the transcystic approach due to reduced morbidity and high success rates of stone extraction.

Abordaje laparoscópico sistemático de la coledocolitiasis

Background: The prevalence of common bile duct stones associated with cholelithiasis increases with age and is about 15 % in the 8th decade of life but its management is still controversial. Some surgeons prefer the single-stage approach with laparoscopy while others suggest the two-stage management with preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy. Objective: The aim of the present study was to evaluate the efficacy of feasibility of single-stage laparoscopic surgery in patients with cholelithiasis and choledocholithiasis. Material and methods: We conducted a retrospective study with prospectively collected data between July 2008 and July 2018. Results: Of 2447 laparoscopic cholecystectomies performed during the study period, 416 presented common bile duct stones. The global success of the transcystic approach to clear common bile duct stones was 81.2%, 70.4% in the cases with preoperative diagnosis of choledocholithiasis and 92.9% for other diagnoses. The rate of complications was 4% without deaths or bile duct injuries. Conclusion: Single-stage laparoscopic surgery is an efficient and safe approach based on the high global success of transcystic exploration. The preoperative diagnosis of choledocholithiasis reduces the efficacy of the procedure due to greater indication of choledocotomy, with complications and longer length of hospital stay.

Porcine Aorto-Renal Artery (PARA) model for laparoscopic transcystic common bile duct exploration: the evolution of a training model to meet new clinical needs

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.