Laparoscopic common bile duct explorationLaparoscopic common bile duct exploration

腹腔鏡總膽管探查術腹腔鏡總膽管探查術

奇美醫學中心　溫義輝奇美醫學中心　溫義輝

IntroductionIntroduction

Biliary T-tube after choledochotomyBiliary T-tube after choledochotomy– Advantage: for decompression / cholangiograpAdvantage: for decompression / cholangiograp

hy / retrieval of retained stonehy / retrieval of retained stone– Disadvantage: high complication rate (15.3%)*, Disadvantage: high complication rate (15.3%)*,

technical requirement (laparoscopic T-tube plactechnical requirement (laparoscopic T-tube placement and suturing)ement and suturing)

*ANZ J of Surgery 2002*ANZ J of Surgery 2002

PurposePurpose

Retrospective comparison of the results of lRetrospective comparison of the results of laparoscopic versus open choledochotomy to aparoscopic versus open choledochotomy to seek methods of prevention of T-tube relateseek methods of prevention of T-tube related complications and check the strategy of d complications and check the strategy of T-tube free approach.T-tube free approach.

Indication for laparoscopic choledochotomyIndication for laparoscopic choledochotomy– Stone not suitable TCyD approach (CHD stone, stone laStone not suitable TCyD approach (CHD stone, stone la

rge than CyD, CyD-CBD junction prevent easy access trge than CyD, CyD-CBD junction prevent easy access to the CBD)o the CBD)

– CBD diameter > 8mmCBD diameter > 8mm– CBD stone number < 10CBD stone number < 10

Contraindication for laparoscopic choledochotomyContraindication for laparoscopic choledochotomy– Large / impacted / too many stones in CBD (CHD)Large / impacted / too many stones in CBD (CHD)– s/p exploratory laparotomys/p exploratory laparotomy

Material and Methods

Materials

13 0

54

16

56 66

68

0

20

40

60

80

100

120

140

L- TCyD L- Chol e Open L- TCyD L- Chol e Open

89年1月~90年12月 91年1月~92年12月

病例

數

Indicated

Non-indicated

Procedures of laparoscopic choledochotomyProcedures of laparoscopic choledochotomy

1.1. LC with routine use of IOCLC with routine use of IOC

2.2. Choledochotomy: electrical cauterization (fine nCholedochotomy: electrical cauterization (fine needle / low electric diathermy current)eedle / low electric diathermy current)

3.3. Choledocholithotomy: choledochoscopy (EHL)Choledocholithotomy: choledochoscopy (EHL)

4.4. Placement of T-tube: tailored T-tube with split aPlacement of T-tube: tailored T-tube with split armrm

5.5. Suturing of CBDSuturing of CBD

6.6. Transfixing sutures (3-0 plain catgut)Transfixing sutures (3-0 plain catgut)

7.7. Completion cholangiography if indicatedCompletion cholangiography if indicated

Methods of choledochotomyMethods of choledochotomyPt. characteristicsPt. characteristics Laparoscopic(n=56)Laparoscopic(n=56) Open(n=68)Open(n=68)

Age (year)Age (year) 56 56 ±14.2±14.2 54 54 ±12.0±12.0Sex (M/F)Sex (M/F) 20/3620/36 28/4028/40s/p PTGBD/PTCDs/p PTGBD/PTCD 1818 2323Acute cholecystitisAcute cholecystitis 2020 2626Suspected/unsuspectedSuspected/unsuspected CBD stonesCBD stones

41/1541/15 49/1949/19

Stone numberStone number 55±3.2±3.2 6 6 ±2.4±2.4Stone size (cm)*Stone size (cm)* 0.5~1.50.5~1.5 0.6~1.80.6~1.8*individual stone*individual stone

All these parameters were not significantly different All these parameters were not significantly different

Result (I)Result (I)

Methods of choledochotomyMethods of choledochotomyLaparoscopic(n=56)Laparoscopic(n=56) Open(n=6Open(n=6

8)8)

FailureFailure 3 ( 5.4%)3 ( 5.4%) 00

small caliber CBDsmall caliber CBD 11

huge stone volumehuge stone volume 11

failure of T-tube placementfailure of T-tube placement 11

Operative duration (min)*Operative duration (min)* 90 90 ±18.6*±18.6* 70 70 ±12.3*±12.3*Mean hospital stage (day)*Mean hospital stage (day)* 5 5 ±± 1.2 1.2 7 ±2.57 ±2.5*p<0.05*p<0.05

Result (II)Result (II)

Methods of choledochotomyMethods of choledochotomyLaparoscopic (n=56)Laparoscopic (n=56) Open Open

(n=68)(n=68)

Retained stonesRetained stones§ § ** 6 (10.7%)*6 (10.7%)* 2 *2 * IHD stonesIHD stones 33 22 CBD microlithiasisCBD microlithiasis 33 00MorbidityMorbidity

Non T-tube relatedNon T-tube related 11 33

retention of wound drainretention of wound drain 11 00 wound infectionwound infection 00 33 T-tube related*T-tube related* 8 (11.8%)*8 (11.8%)* 1*1* biliary leakagebiliary leakage 11 11 dislodge of T-tubedislodge of T-tube 44 00 disruption of T-tube disruption of T-tube tract (with biletract (with bile peritonitis)peritonitis)

33 00

§§ detected by routine post-operative cholangiographic and chole-doc detected by routine post-operative cholangiographic and chole-dochoscopic examinationhoscopic examination

** p<0.05 p<0.05

Result (III)Result (III)

Complications (No. of Complications (No. of Pts)Pts)

Management Management OutcomeOutcome

Retained stones (7)Retained stones (7) Choledochoscopic retrievalCholedochoscopic retrieval Success Success

Early bile leakage (1) Early bile leakage (1) Correction of T-tube axisCorrection of T-tube axis ImproveImproved d

Disruption of T-tube tract Disruption of T-tube tract with biliary peritonitis (3)with biliary peritonitis (3)

Endoscopic placement of draEndoscopic placement of drainage tubeinage tube

ImproveImproved d

Outcome of biliary complication after Outcome of biliary complication after laparoscopic choledochotomylaparoscopic choledochotomy

Discussion(I)Discussion(I)

In this study, almost laparoscopic cIn this study, almost laparoscopic choledochotomy were successfully choledochotomy were successfully completed, but there were significanompleted, but there were significantly higher incidence of retained stotly higher incidence of retained stones and T-tube related complicationes and T-tube related complication.n.

Discussion(II)Discussion(II)

In case needing T-tube drainage, the techniqIn case needing T-tube drainage, the technique of choledochotomy and T-tube placemenue of choledochotomy and T-tube placement should be familiarized (including incision t should be familiarized (including incision of small caliber CBD, indwelling o tailored of small caliber CBD, indwelling o tailored T-tube with split arm and fixation of T-tubT-tube with split arm and fixation of T-tube), and the quality of T-tube should be prope), and the quality of T-tube should be properly selected (Latex > Silicon).erly selected (Latex > Silicon).

Discussion(III)Discussion(III)

In case suitable for T-tube-free laparoscopIn case suitable for T-tube-free laparoscopic choledochotomy, stone clearance should ic choledochotomy, stone clearance should be aggressively attempted and definitely cbe aggressively attempted and definitely confirmed by thorough choledochoscopic eonfirmed by thorough choledochoscopic examination and standard completion cholaxamination and standard completion cholangiography.ngiography.

ConclusionConclusion

1.1. Single stage laparoscopic choledochotomy, incluSingle stage laparoscopic choledochotomy, including laparoscopic cholecystectomy and choledocding laparoscopic cholecystectomy and choledocholithotomy is feasible and safe for patients with holithotomy is feasible and safe for patients with CBD stones.CBD stones.

2.2. T-tube related complications should be preventeT-tube related complications should be prevented in laparoscopic choledochotomy with T-tube d in laparoscopic choledochotomy with T-tube drainage procedures and duct clearance should bdrainage procedures and duct clearance should be confirmed in T-tube free procedures. e confirmed in T-tube free procedures.