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Latif J, Mountjoy P, Lewis H, Bhatti I, Awan A. Robotic assisted common bile duct exploration for management of complex gallstone disease. Int J Surg 2024; 110:6418-6425. [PMID: 38896861 PMCID: PMC11486968 DOI: 10.1097/js9.0000000000001817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/01/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Minimally invasive cholecystectomy and common bile duct exploration offers single-stage management for complex gallstone disease (cholelithiasis and choledocholithiasis). The Robotic platform presents benefits in improving operative precision, which has not been extensively evaluated in the acute setting of managing complex gallstone disease, as well as in performing transcholedochal or postcholecystectomy common bile duct exploration. The authors report an early series of emergent and expedited robotic-assisted cholecystectomy with common bile duct exploration (RC-CBDE) or robotic common bile duct exploration (R-CBDE) alone. MATERIAL AND METHODS A retrospective analysis from a specialist unit in the United Kingdom was undertaken from April 2022 to September 2023, inclusive. All patients who underwent RC-CBDE or R-CBDE were included. Data was collated on patient demographics, perioperative investigations, intraoperative approach, and postoperative outcomes. RESULTS Twenty-three consecutive patients were identified. The median (IQR) age was 51 (33-66) years. Median (IQR) Charlson Comorbidity Index (CCI) was 1 (0-4). Five patients underwent operative intervention as an emergency and 18 on an expedited basis. Two patients underwent postcholecystectomy R-CBDE. Fourteen (61%) were transcholedochal and nine were transcystic (39%) CBDE. Median (IQR) bilirubin was 51 (34-253). Median (IQR) operative time was 176 (124-222) minutes. Median (IQR) postoperative length of stay was 2 (0-4) days. There were no bile leaks requiring intervention. The clearance rate of CBDS was 100%. No patients developed postoperative pancreatitis. One patient required intervention for port site hernia following RC-CBDE. One patient developed subhepatic collection postoperatively and required laparoscopic washout and placement of drains. No patients had retained stones after a 3-month follow-up. CONCLUSION Early experience confirms that RC-CBDE and R-CBDE in feasible, safe, and effective treatment for complex gallstone disease. Integrated adjuncts (intraoperative robotic ultrasound - IORUS and Firefly - fluorescence guided surgery - FGS) and superior ergonomics of the robotic platform may assist in reducing the learning curve and increase wider uptake of this complex procedure.
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Affiliation(s)
- Javed Latif
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby and Burton
| | - Poppy Mountjoy
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby and Burton
| | - Harrison Lewis
- University of Nottingham Medical School, Lenton, United Kingdom
| | - Imran Bhatti
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby and Burton
| | - Altaf Awan
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby and Burton
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Pardo F, Vidal L, Cremades M, Cugat E. Robotic cholecystectomy and transcystic common bile duct exploration with augmented reality glasses and indocyanine green in a patient with a cystic duct cyst. Cir Esp 2023; 101:562-563. [PMID: 36403714 DOI: 10.1016/j.cireng.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/28/2022] [Accepted: 10/21/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Fernando Pardo
- Department of General and Digestive Surgery, HPB unit, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - Laura Vidal
- Department of General and Digestive Surgery, HPB unit, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Manel Cremades
- Department of General and Digestive Surgery, HPB unit, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Esteban Cugat
- Department of General and Digestive Surgery, Hospital Universitario Mutua Terrassa, Terrassa, Barcelona, Spain
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Chao P, Chandhok S, Koea J, Srinivasa S. Letter Regarding: Robotic Cholecystectomies: What are They Good for?-A Retrospective Study of Robotic Versus Conventional Cases. J Surg Res 2023; 281:335-336. [PMID: 36202667 DOI: 10.1016/j.jss.2022.07.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Phillip Chao
- Upper GI Unit, Department of Surgery, North Shore Hospital, Auckland, New Zealand; Waitematā Clinical Campus, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Simran Chandhok
- Upper GI Unit, Department of Surgery, North Shore Hospital, Auckland, New Zealand; Waitematā Clinical Campus, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Jonathan Koea
- Upper GI Unit, Department of Surgery, North Shore Hospital, Auckland, New Zealand; Waitematā Clinical Campus, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Sanket Srinivasa
- Upper GI Unit, Department of Surgery, North Shore Hospital, Auckland, New Zealand; Waitematā Clinical Campus, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Chandhok S, Chao P, Koea J, Srinivasa S. Robotic-assisted cholecystectomy: Current status and future application. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2022. [DOI: 10.1016/j.lers.2022.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Helton WS, Ayloo S. Technical Aspects of Bile Duct Evaluation and Exploration: An Update. Surg Clin North Am 2019; 99:259-282. [PMID: 30846034 DOI: 10.1016/j.suc.2018.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
| | - Subhashini Ayloo
- Rutgers, New Jersey Medical School, 185 South Orange Avenue, MSB G586, Newark, NJ 07103, USA.
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6
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Lee KF, Fung AKY, Lok HT, Fong AKW, Chong CCN, Lai PBS. Robot-assisted minimally invasive procedures for complicated biliary stone disease. Hepatobiliary Surg Nutr 2018; 7:185-188. [PMID: 30046569 DOI: 10.21037/hbsn.2017.05.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Kit Fai Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Andrew K Y Fung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hon Ting Lok
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anthony K W Fong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Charing C N Chong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Paul B S Lai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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7
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Li M, Konstantinova J, Xu G, He B, Aminzadeh V, Xie J, Wurdemann H, Althoefer K. Evaluation of stiffness feedback for hard nodule identification on a phantom silicone model. PLoS One 2017; 12:e0172703. [PMID: 28248996 PMCID: PMC5383005 DOI: 10.1371/journal.pone.0172703] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 02/08/2017] [Indexed: 11/18/2022] Open
Abstract
Haptic information in robotic surgery can significantly improve clinical outcomes and help detect hard soft-tissue inclusions that indicate potential abnormalities. Visual representation of tissue stiffness information is a cost-effective technique. Meanwhile, direct force feedback, although considerably more expensive than visual representation, is an intuitive method of conveying information regarding tissue stiffness to surgeons. In this study, real-time visual stiffness feedback by sliding indentation palpation is proposed, validated, and compared with force feedback involving human subjects. In an experimental tele-manipulation environment, a dynamically updated color map depicting the stiffness of probed soft tissue is presented via a graphical interface. The force feedback is provided, aided by a master haptic device. The haptic device uses data acquired from an F/T sensor attached to the end-effector of a tele-manipulated robot. Hard nodule detection performance is evaluated for 2 modes (force feedback and visual stiffness feedback) of stiffness feedback on an artificial organ containing buried stiff nodules. From this artificial organ, a virtual-environment tissue model is generated based on sliding indentation measurements. Employing this virtual-environment tissue model, we compare the performance of human participants in distinguishing differently sized hard nodules by force feedback and visual stiffness feedback. Results indicate that the proposed distributed visual representation of tissue stiffness can be used effectively for hard nodule identification. The representation can also be used as a sufficient substitute for force feedback in tissue palpation.
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Affiliation(s)
- Min Li
- School of Mechanical Engineering, Xi’an Jiaotong University, Xi’an, Shaanxi, China
- State Key Laboratory for Manufacturing Systems Engineering, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Jelizaveta Konstantinova
- School of Engineering and Materials Science, Queen Mary University of London, London, United Kingdom
| | - Guanghua Xu
- School of Mechanical Engineering, Xi’an Jiaotong University, Xi’an, Shaanxi, China
- State Key Laboratory for Manufacturing Systems Engineering, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Bo He
- School of Mechanical Engineering, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | | | - Jun Xie
- School of Mechanical Engineering, Xi’an Jiaotong University, Xi’an, Shaanxi, China
- State Key Laboratory for Manufacturing Systems Engineering, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Helge Wurdemann
- Department of Mechanical Engineering, University College London, London, United Kingdom
| | - Kaspar Althoefer
- Faculty of Science & Engineering, Queen Mary University of London, London, United Kingdom
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Abstract
Hepatobiliary (HB) surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive HB surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant to adopt the approach. Recently development of the robotic platform has provided a tool that can overcome many of the limitations of conventional laparoscopic HB surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera combine to allow steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive HB and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted HB surgery.
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Szold A, Bergamaschi R, Broeders I, Dankelman J, Forgione A, Langø T, Melzer A, Mintz Y, Morales-Conde S, Rhodes M, Satava R, Tang CN, Vilallonga R. European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery. Surg Endosc 2015; 29:253-88. [PMID: 25380708 DOI: 10.1007/s00464-014-3916-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/19/2014] [Indexed: 12/14/2022]
Abstract
Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.
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Affiliation(s)
- Amir Szold
- Technology Committee, EAES, Assia Medical Group, P.O. Box 58048, Tel Aviv, 61580, Israel,
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Costi R, Gnocchi A, Di Mario F, Sarli L. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. World J Gastroenterol 2014; 20:13382-13401. [PMID: 25309071 PMCID: PMC4188892 DOI: 10.3748/wjg.v20.i37.13382] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/23/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.
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Milone L, Coratti A, Daskalaki D, Fernandes E, Giulianotti PC. [Robotic hepatobiliary and gastric surgery]. Chirurg 2013; 84:651-64. [PMID: 23942961 DOI: 10.1007/s00104-013-2581-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Hepatobiliary surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive hepatobiliary surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant about the approach. On the other hand, gastric surgery is a very popular field of surgery with an extensive amount of literature especially regarding open and laparoscopic surgery but not much about the robotic approach especially for oncological disease. Recent development of the robotic platform has provided a tool able to overcome many of the limitations of conventional laparoscopic hepatobiliary surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera, allow for steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive hepatobiliary and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted hepatobiliary and gastric surgery.The English full-text version of this article is available at SpringerLink (under supplemental).
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Affiliation(s)
- L Milone
- Department of Surgery, Division of Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood MC 958 Room 435 E, 60612, Chicago, IL, USA
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Zhu XQ, Ding C, Zhang M, Guan XQ, Chen Y. Therapeutic value of laparoscopy combined with choledochoscopy for common bile duct stones: An analysis of 107 cases. Shijie Huaren Xiaohua Zazhi 2012; 20:2496-2499. [DOI: 10.11569/wcjd.v20.i26.2496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the value of laparoscopy combined with choledochoscopy in the treatment of common bile duct stones.
METHODS: The clinical data for 107 patients with choledochlithiasis who underwent laparoscopic common bile duct exploration and stone removal with choledochosopy from April 2008 to March 2011 at our hospital was retrospectively analyzed to explore their therapeutic value.
RESULTS: Of 107 patients, 102 had successful laparoscopy and choledochoscopy, and 5 underwent a conversion to laparotomy. Total operative time was 120-150 min (average 140 min). Blood loss was 20-80 mL (average 55 mL). Postoperative hospitalization length was 7-15 d (average 8. 5 d). Peritoneal drainage tubes were placed in 83 cases; 16 cases only had little pale yellow drainage fluid on the first postoperative day, and their tubes were removed on the fourth postoperative day after no fluid was drained for 3 d. About 300 mL of fluid was drained on the first postoperative day in the remaining patients, and their tubes were removed on the sixth postoperative day after no fluid was drained for 4 d. T-tubes were removed 4 wk postoperatively. All of the patients recovered well and were followed up for 3 to 6 months. No patients developed bile leakage, residual stones, or bile duct stricture.
CONCLUSION: Laparoscopy combined with choledochoscopy has good efficacy and fewer complications and is less invasive in the management of common bile duct stones.
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Primary closure following laparoscopic common bile duct exploration combined with intraoperative cholangiography and choledochoscopy. World J Surg 2012; 36:164-70. [PMID: 22086256 DOI: 10.1007/s00268-011-1346-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) has become one of the main options for treating choledocholithiasis associated with cholelithiasis. Our objective was to assess the short-term outcomes of patients undergoing laparoscopic primary closure of the common bile duct (CBD) compared with laparoscopic choledochotomy plus T-tube drainage. METHODS We retrospectively studied 137 patients undergoing primary closure following LCBDE (group A) compared with 102 cases with laparoscopic choledochotomy plus T-tube drainage (group B) between January 2007 and January 2010. Intraoperative cholangiography (IOC) and choledochoscopy were performed in all patients. RESULTS Three patients in group A (2.2%) were converted to open surgery and two (2.0%) in group B because of serious adherence. According to routine IOC, unexpected CBD stones were found in 16 cases (6.8%). The duration of the operation in group A was shorter than in group B (92.4 ± 15.2 vs. 125.7± 32.6 min, P < 0.05), as was length of postoperative stay (3.1± 2.4 vs. 5.7± 4.3 days, P < 0.05). Postoperative bile leakage occurred in six patients (4.5%) in group A and four cases (4.0%) in group B; all of the patients recovered after simple drainage without reoperation. Bile peritonitis was seen in one case after T-tube removal. The median follow-up was 26 months. There were no recurrences. CONCLUSIONS Laparoscopic primary closure of the CBD is safe and successful for the management of CBD stones. Application of IOC and choledochoscopy to ensure clearance of the CBD and careful suturing are essential for primary closure.
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