[Laparoscopy in Hepatobiliary Surgery] Exploration through the common gallbladder

Biliary tract surgery is a branch of hepatobiliary surgery, which mainly deals with diseases related to the biliary system through surgical methods. The biliary system mainly includes extrahepatic and extrahepatic bile ducts and the gallbladder. With the continuous deepening of biliary anatomy research, continuous updating of surgical techniques and equipment, and continuous improvement of treatment concepts, biliary surgery has been in a state of vigorous development in recent years.

Improvement and popularization of biliary surgery

Over the past two decades, the development of biliary surgery has made extraordinary achievements. However, compared with liver surgery and pancreas surgery in the same period, it is still much inferior. In biliary tract surgery, biliary stone disease is the most common type of disease with a large number of patients, and the treatment method is still based on cholecystectomy. The introduction of laparoscopic technology is only a new surgical technique. It is completely consistent with the treatment of gallstones more than 100 years ago. Research on stone prevention is still lingering. Recent studies on the susceptibility genes of cholelithiasis families and patients with cholesterol gallstones have not yet uncovered the full picture of the pathogenesis of cholelithiasis, which is a subject to be studied.

Biliary tract surgery is an operation that must be mastered, but unplanned reoperations also greatly trouble the surgeon. Due to ignorance of surgical principles, unclear purpose, and underestimation of difficulties, resulting in residual stones, biliary tract damage, unreasonable surgical methods, and wrong surgical methods, reoperation of biliary tract requires strengthening of theoretical knowledge and surgical experience in biliary tract surgery.

Characteristics of different developmental stages of biliary tract surgery

Traditional Biliary Exploration

An incision is made from the right costal margin or through the rectus abdominis muscle, about 15-25 cm in length; after gallbladder removal, a routine duodenal peritoneal incision is required to free the descending part of the duodenum, and the common bile duct is cut longitudinally on the forearm Open 1.5-2cm. Stones were removed using conventional instruments (lithograph forceps, biliary probe, irrigation tube), and T-tubes were routinely indwelled.

Traditional features and disadvantages: blindness, high rate of residual stones (more than 10% outside the liver), high and serious biliary tract damage.

The Era of Cholangiography

Cholangiography can reduce the residual stone rate to about 7%. After the T tube is placed, if there are residual stones, it will increase the operation time and bile duct damage. The characteristic is that the state of blind exploration has been partially improved, but it is still unable to reduce the damage and change the surgical method.

The era of choledochoscopy

Choledochoscopy and choledochoscopy techniques are widely used clinically, and have become one of the most important minimally invasive techniques in biliary surgery-hepatic surgery. The choledochoscopy technique does not require peritoneal incision on the side of the duodenum. Theoretically, the residual stone rate in the extrahepatic bile duct is 0, but the actual residual stone rate is 2%. The incision opening of the bile duct wall was reduced by about 5-6mm. It is characterized by direct observation of the bile duct wall and the opening of the lower end of the bile duct, avoiding damage and edema caused by blind exploration, and reducing the causes of postoperative biliary fistula and stenosis. Alternative surgery is now possible!

The Road to Minimally Invasiveness—Wide Application of Laparoscopy

Beijing Hospital began laparoscopic cholecystectomy (LC) in 1993. At present, more than 93% of cholecystectomy is done under laparoscopy, and open cholecystectomy has gradually withdrawn from the stage. The application of laparoscopic technique for extrahepatic bile duct stones is ideally laparoscopy + choledochoscopy + endoscopy + nasobiliary duct + T-tube + internal stent. How to adjust the concept and integrate modern technology is worth pondering.

With the development of laparoscopic surgery, laparoscopic common bile duct exploration (LCBDE) is increasingly used in patients with common bile duct stones. Like LC, LCBDE has the advantages of less trauma, less postoperative pain, and shorter hospital stay. Because of its single operation procedure, combined with the use of choledochoscope, stone extraction is easier than ES.

Exploration indications

1. Recent or current jaundice.

2. Preoperative ERCP or intraoperative X-ray examination showed stones.

3. Palpable stones during operation.

4. Common bile duct dilation exceeds 10mm.

5. Multiple gallbladder stones and thick cystic duct.

6. Aspirate cloudy bile from the gallbladder.

7. Common bile duct wall thickening.

Surgery preparation

The skin is prepared as usual, paying special attention to the cleanliness of the navel.

Poke location

10mm and 5mm trocars were placed on the inferior umbilicus, inferior to the xiphoid process, and the anterior axillary line of the right costal margin, respectively.

Steps

1. Open the lower edge of the umbilical cord into the abdomen, insert a 10mm puncture device, inject CO2 and gas into the abdomen, and set the pressure at 14mmHg.

2. Under laparoscopic monitoring, place the remaining two trocars separately.

3. Retrograde gallbladder resection, the cystic duct is not cut off after ligation.

4. Cut the front wall of the common bile duct, the incision is slightly larger than the diameter of the T tube.

5. The choledochoscope enters the abdominal cavity through the puncture device under the xiphoid process, and the common bile duct is explored, and the stone can be removed with a basket.

6. After removing the stones, place the corresponding T tube in the common bile duct, and suture the bile duct incision with 1~2 stitches.

7. Cut off the cystic duct and take out the gallbladder specimen from the hole under the xiphoid process.

8. Make an incision at the surface projection of the common bile duct in the right upper abdomen, lead out the T tube from the incision, fix it on the skin and connect it with a low negative pressure suction device.

9. Flush the abdominal cavity, place a negative straw in the upper right abdomen, poke a hole from the anterior axillary line, and fix it on the abdominal wall.

10. Suture the puncture hole under the xiphoid process and the umbilicus.

Bile duct incision

Once the decision is made to proceed with transbiliary exploration, the surgeon may remain on the patient's left side or move to the patient's right side and place an additional trocar in the lower right quadrant between the outermost trocar and the surgical needle . The camera facilitates dissection. Operating from the right provides a comfortable angle for tracheotomy and suturing. When the surgeon is on the right side, the surgeon uses the most lateral trocar plus the trocar in the lower right quadrant, while the assistant moves to the left side of the patient and retracts the head of the gallbladder using the subxiphoid trocar . The superior duodenal common bile duct can be seen as a bluish-green tubular structure on the right anterior side of the hilum. The peritoneal covering of the hepatoduodenal ligament should be dissected anterior to the bile duct and the bile duct should be exposed using a blunt dissection. Dissection along its lateral and medial sides and attempting to wrap around the bile duct should be avoided, as this would injure the "3 o'clock" and "9 o'clock" arteries that supply air and run parallel to the bile duct. Exposure should be sufficient to allow a 1–2 cm longitudinal incision on the catheter.If there is doubt about the location of the bile duct, bile can be aspirated using a fine needle to confirm the location of the bile duct. A longitudinal incision is preferred so as not to interrupt the blood supply to the common bile duct. The incision can be made with a laparoscopic knife or fine scissors. Indwelling sutures are usually unnecessary and risk tearing, tearing the catheter. Due to the ability of CBD to expand and stretch, the incision length should generally be kept less than 1.5 cm. Remember not to make the incision to the right of the ductal midplane, lest the incision cut into the gallbladder duct - a common ductal septum, which occurs in about 20% of patients when the gallbladder duct runs parallel to the ductal line.

Stone extraction

Extraction of stones by choledochotomy can be done in a number of ways. In general, it is recommended to start with the simplest operations and, if necessary, proceed to more complex operations:

1. Irrigation: The surgeon places the tip of the suction irrigator into the choledochotomy to irrigate the catheter. Small stones and debris are easily removed with this simple maneuver, and larger free-floating stones can be pulled towards the choledochotomy following the flow of saline. Once seen at the choledochotomy, these larger stones can be grasped and removed. A 14F red rubber catheter can also be inserted into the 5 mm trocar and threaded distally or proximally and flushed vigorously as it is withdrawn to remove more distal stones.

2. Balloon extraction: A Fogarty balloon catheter or ERCP stone extraction balloon passed over the wire (on the nipple) is passed through the choledochotomy and directed distally. The balloon is guided over the resistance, then slowly withdrawn and inflated, followed by gradual withdrawal through the choledochotomy to remove debris. This technique may require multiple passes over the balloon to remove all debris.

Closure

In simple cases, only an initial closure is sufficient, where there is little to no manipulation of the nipple, no purulence in the bile ducts, little concern for stones and relatively healthy patients. The catheter can be closed in intermittent or continuous fashion using fine absorbable 4-0 sutures such as Vicryl (polylactic acid 910) or PDS (polydioxane). The running technique has greater convenience than the breaking technique. Suture occlusion should be full thickness, approximately 1-2 mm from the incisional edge of the catheter, and spaced every 2 mm. Sutures should be tested by flushing saline through the cystic duct using a cholangiographic catheter while observing for saline leakage. Place additional interrupted sutures where the leak occurred and recheck closure. A closed cholangiogram should also be performed to check for contrast extravasation and to confirm the patency of the catheter and the presence of a filling defect.The main advantage of primary closure is that the patient does not require prolonged T-tube drainage and avoids the potential discomfort and potential complications associated with the T-tube. However, one of the disadvantages of primary closure is that the risk of bile leakage may be greater if bile duct compression is performed postoperatively, as in extensive nipple manipulations or in settings where the risk of stone retention is high. Bile drainage may also be impaired in cases of ampulla edema or cholangitis. However, in carefully selected patients, there is evidence that this technique results in shorter operative time, shorter hospital stays, and may actually be associated with lower complication rates than T-tube closure.

T-pipe closed

U-tubes are the traditional adjunct to choledochotomy and are commonly used by some surgeons, including the senior author. Regular users believe that instrumentation of the common bile duct and procedures used for stone removal may cause papilledema and increased pressure within the biliary tree, thereby creating an environment that makes closure a risk of bile leakage. T-tube placement resolves edema and spasm while preventing cholestasis. In patients with cholangitis, ensuring continuous drainage of bile is especially important to prevent recurrent cholangitis and ensure resolution of sepsis. The T-tube also provides continuous access to the biliary system for septal cholangiography, removal of any retained stones or to facilitate subsequent ERCP sampling. The advantage of the T-tube technique over using an internal biliary stent is that the biliary prosthesis can be removed by simply pulling the T-tube at the bedside without the need for additional endoscopy as with a biliary stent. Placement of a T-tube into the common bile duct is more extensive and will be the only technique described, although gallbladder drainage may also be performed in some patients (as an alternative to a T-tube). The size of the T-tube used by surgeons varies, with some surgeons advocating the use of a 14F T-tube for easier percutaneous access when needed.The senior author preferred the use of an 8F tube because it reduces patient discomfort and requires a smaller bile duct opening. A T-tube is made by trimming the crossbar of the T to approximately twice the size of the choledochotomy of one long and short limb. The crossbar segment is then cut longitudinally to open the posterior wall, and the long tube is inserted into the catheter in the distal catheter. The choledochotomy was closed in a serial fashion using 4-0 Vicryl running sutures. The first sip is the most important, being careful not to bind the tube snugly. The first bite should hold the tube snug against the pipe, which is critical for anchoring the tube and preventing migration or leaks. Subsequent bites move caudally until the duct is fully closed. The T-tube was then externalized at the end of the surgical procedure through one of the 5 mm trocar sites in the upper right quadrant. It is important to allow a small amount of slack in the tube so that postoperative abdominal distension does not put tension on the tube and cause it to dislodge. Even with a T-tube placed, a closed oil suction port adjacent to the T-tube is recommended to help detect and control possible postoperative bile leaks. Although T-tube management after surgery varies widely among surgeons, most surgeons leave the tube in place for at least 2 to 6 weeks.

The senior author's technique using the 8F T-tube will be described. After surgery, the surgeon leaves the drainage bag on the floor for about 12 hours while the closed suction port is checked for signs of bile leaks. If the drainage is not smooth, the T-tube is repositioned at bed level for an additional 12 hours. After this time, place the bag next to your bed. If bile is not seen in the closed suction port, clamp the T-piece tightly. It is believed that this method, with its various positional variations, may allow testing the integrity of the repaired choledochotomy by sequentially varying the intraductal pressure. The closed drain was then removed before discharge, and the patient was scheduled for cholangiography 10-15 days postoperatively. If there are no remaining stones or bile leakage, the T-tube is removed. If retained stones are present, they are removed endoscopically.

Primary biliary closure

Primary closure with a biliary stent is a newer technique that combines the simplicity of primary closure with the internal drainage provided by a transampullary stent. Before the choledochotomy is closed, the surgeon inserts a biliary stent through the choledochotomy. A laparoscopic 7F biliary stent (Fanelli Stent, Cook Medical) or an 8.5F biliary stent designed for ERCP deployment can be used. If an ERCP-type stent is used, it is recommended to secure its pre-secured 5–7 cm stent to the delivery catheter with sutures and be able to be repositioned by withdrawing the catheter.The surgeon obtains a wire channel through the nipple and then loads the stent delivery system back onto the wire. Stent delivery systems typically have fluoroscopic markers positioned across the nipple, and once in place, the stent is deployed. A choledochoscope can be used to confirm the placement of a stent across the nipple from the side of the common bile duct. The stent does not need to span the choledochotomy closure site, but instead serves to ensure continued internal drainage after choledochotomy closure, preventing pressurization of the bile duct and the consequent potential for bile leakage.Once the stent was in place and the choledochotomy was closed, the surgeon performed a cholangiogram to confirm a watertight closure of the choledochotomy with no filling defect. A closed drain was placed close to the choledochotomy closure to monitor for postoperative bile leakage. The drain is usually removed before the patient is discharged from the hospital. The EGD was planned to be removed from the biliary stent after 2 to 4 weeks in the outpatient setting. Using foreign body forceps or a snare, remove the stent using a standard gastroscope. A clear cover can be fitted to the end of the gastroscope to facilitate visualization of the nipple and grasp the holder if necessary.

Precautions

1. Bleeding was mainly caused by inadvertent damage to the mutated cystic artery, right hepatic artery, and hepatic artery and vein. Occasionally, the portal vein runs before the common bile duct. If the common bile duct is not carefully dissected along the cystic duct, and the possibility of portal vein is not ruled out by puncture, once it is mistakenly identified as the "common bile duct" of the portal vein, it will cause massive bleeding and endanger the life of the patient. In addition, piercing the common bile duct with a sharp knife can easily penetrate the anterior and posterior walls of the common bile duct, and even injure the portal vein behind the common bile duct. Improper use of electric hooks and electric scissors around the dissected bile duct will also damage the surrounding important blood vessels and cause bleeding.

2. The main causes of bile leakage are loose sutures around the T tube, abnormal accessory bile duct or vagus bile duct injury that has not been found and treated, and residual stones or stenosis at the lower end of the bile duct.

3. The incidence of residual bile duct stones is higher when there are more emergency operations and more bile duct stones. After 6 to 8 weeks after the T-tube sinus is completely formed, choledochoscopy can be used to remove stones.

4. Most of the residual stones in the abdominal cavity were caused by multiple and fragile stones, and no gauze was placed in the Veneer's hole, and the removed stones were not put into the specimen bag in time. Stones remaining in the abdominal cavity can become the main cause of abdominal infection and intestinal adhesion.

5. Visceral injury The surrounding organs that are easy to be damaged include the duodenum, transverse colon, stomach, liver, and diaphragm. The main reasons were improper use of electric knife, insufficient intestinal preparation, rough and irregular technical operation.