Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery

Summary

Programmed surgery based on surgical methods and anatomical markers helps shorten the operation time, reduce complications, and improve the safety of the surgery. This study investigated and summarized the surgical methods and anatomic markers of laparoscopic common bile duct exploration in patients with a history of biliary tract surgery.

Abstract

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs easily when performing another operation for laparoscopic common bile duct exploration (LCBDE), which was once considered a relative contraindication. In view of the limitations of the current surgical technique, this study summarized the surgical approaches and crucial anatomical landmarks for reoperation for LCBDE. Four general surgical approaches were proposed to expose the common bile duct, including the ligamentum teres hepatis approach, the anterior hepatic duodenal ligament approach, the right hepatic duodenal ligament approach, and the hybrid approach. Additionally, this study highlighted seven crucial anatomical landmarks: the parietal peritoneum, the gastrointestinal serosa, the ligamentum teres hepatis, the inferior margin of the liver, the gastric antrum, the duodenum, and the hepatic flexure of the colon, which were helpful to safely separate abdominal adhesions and expose the common bile duct. Moreover, to shorten the time of choledocholithotomy, a sequential method was innovatively applied for the removal of the stones in common bile duct. Mastering the above surgical approaches, including identifying crucial anatomical landmarks and adopting the sequential method will improve the safety of reoperation for LCBDE, shorten the operation time, promote the fast recovery of patients, reduce postoperative complications, and contribute to the popularization and application of this technique.

Introduction

Choledocholithiasis is one of the most common biliary tract diseases, with a high recurrence rate¹. Because recurrent choledocholithiasis often involves multiple stones, coupled with the fact that endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) may damage the function of Oddi's sphincter as well as cause repeated retrograde biliary tract infections, patients with recurrent choledocholithiasis often require two or more surgical operations².

With the popularization of minimally invasive surgery and the advancement of laparoscopic techniques, laparoscopic common bile duct exploration (LCBDE) has been widely used in clinical practice, thanks to such advantages as minimal trauma, rapid recovery, and preservation of the function of Oddi's sphincter³. Abdominal adhesions in patients with recurrent choledocholithiasis lead to changes in anatomical structure, so these patients are susceptible to a secondary injury in a subsequent bile duct exploration. Therefore, abdominal adhesions have been considered a contraindication of laparoscopic surgery^4,5. With further technological development, LCBDE has been preliminarily confirmed to be feasible in patients with a history of biliary tract surgery^6,7,8.

However, relevant studies have been limited, and more in-depth research into this surgical technique is still needed. Programmed operations for LCBDE are often lacking, especially for patients with extensive abdominal adhesions. Based on this situation, the present study aims to develop a programmed procedure by investigating the surgical approaches and anatomical landmarks of LCBDE in patients with a history of biliary tract surgery. A programmed operation based on surgical approaches and anatomical landmarks can help to shorten the operation, reduce complications, and improve surgical safety^9,10.

Protocol

A total of 177 patients with a history of biliary tract surgery who underwent LCBDE between September 2010 and December 2021 were included. This study was approved by the institutional review board in The First Affiliated Hospital of Jinan University. All patients provided written informed consent.

1. Inclusion criteria

1. Include patients with more than two stones in the common bile duct (CBD).
2. Include patients with CBD stones that have a total diameter of ≥20 mm.
3. Include patients with a CBD diameter of ≥10 mm.

2. Exclusion criteria

1. Exclude patients with hepatolithiasis.
2. Exclude patients with acute obstructive suppurative cholangitis.
3. Exclude patients with a Child-Pugh liver function of class B or class C.
4. Exclude patients with scheduled simultaneous biliary anastomosis.
5. Exclude patients with an intolerance to general anesthesia due to a poor general condition.

3. Preoperative preparation

1. Administer preoperative blood tests including a complete blood count, liver and renal function test, and coagulation function test.
2. Administer preoperative hepatobiliary color Doppler ultrasound, upper abdominal computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP).

4. Establishment of pneumoperitoneum and trocar placement under general anesthesia with tracheal intubation

1. Use a Veress needle to establish pneumoperitoneum routinely (Veress method)¹¹.
   1. Make a 10 mm long incision on the skin below the umbilicus, then clamp and lift up the skin on both sides of the incision. Insert the Veress needle into the abdominal cavity through the incision. Then, inject carbon dioxide gas and maintain a pneumoperitoneum pressure of 12 mmHg.
2. If the Veress method fails, change to the open method (Hasson method)¹¹.
   1. Using the conventional laparotomy method, incise the abdominal wall layer by layer to the depth along the skin incision made by the Veress method to reach the abdominal cavity. Place the observation port into the abdominal cavity through this incision. Inject carbon dioxide gas and maintain a pneumoperitoneum pressure of 12 mmHg.
3. Place the observation port (the first trocar) around the umbilicus as far as possible to fully explore the abdominal cavity. At the same time, keep the first trocar at least 5 cm away from the previous open incision, or at least 2 cm away from the previous laparoscopic incision, to avoid damage to the intestine adhered to the abdominal wall.
4. According to the adhesion situation observed in abdominal cavity exploration, arrange the trocars typically in a triangular shape with the surgical area as the target. At the same time, take the separation of adhesions, choledochoscopic lithotomy, and T-tube and drainage tube indwelling into consideration.

5. Surgical approaches

1. Hepatic round ligament approach: Separate and release the abdominal adhesions along the hepatic round ligament to the inferior liver margin, and then to the hepatic hilum in order to expose the CBD.
2. Anterior hepatoduodenal ligament approach: Separate the duodenum from the hepatic hilum downward to expose the CBD anterior to the hepatoduodenal ligament.
3. Right hepatoduodenal ligament approach: Separate the hepatic flexure of the colon, adhered to the hepatic hilum, from the hepatic hilum, starting from the right lateral side of the hepatoduodenal ligament downward to expose the area between the right subhepatic space and the omental foramen, thereby determining the position of the CBD.
4. Hybrid approach: Combine two or three of the above approaches.
   NOTE: This mainly depends on the location of adhesion.
   1. If there is adhesion in the middle of the anterior abdominal wall, use the hepatic round ligament approach.
   2. If there is adhesion in the front and on both sides of the CBD, use the anterior hepatoduodenal ligament approach.
   3. If there is adhesion in the right upper abdomen, use the right hepatoduodenal ligament approach.
   4. If there is extensive adhesion in the abdominal cavity, use the hybrid approach. The hybrid approach is the most commonly used method in this study.
   5. Use the above three approaches flexibly and alternately, and start the separation from near to far, from simple to complex, and from loose tissues to adhered and dense tissues.

6. Adhesion separation and CBD exposure based on anatomical landmarks

1. Parietal peritoneum and gastrointestinal serosa: Use noninvasive grasping forceps to clamp and pull the gastrointestinal tract adhering to the abdominal wall with appropriate traction tension, and separate and release the adhesions close to the parietal peritoneum and away from the gastrointestinal serosa.
   1. Separate the loose adhesions with a blunt dissection or ultrasonic scalpel, and release the dense adhesions or adhesions involving intestines with scissors to avoid thermal damage (Figure 1).
2. Hepatic round ligament: In patients with a history of biliary tract surgery, there are often mutual adhesions between the gastric antrum, duodenum, liver, and abdominal wall. Find the inferior liver margin by separating the adhesions upward along the hepatic round ligament, and expose the gastric antrum and the duodenum (Figure 2 and Figure 5).
3. Inferior liver margin: After exposing the inferior liver margin through the hepatic round ligament, separate the adhesions downward along the visceral surface of the liver, and further expose the gastric antrum and the duodenum. Separate the adhesions at this location close to the liver, under the principle of injuring the liver rather than the gastrointestinal tract if injury is unavoidable (Figure 3, Figure 4, and Figure 5).
4. Gastric antrum and duodenum: The gastric antrum and the first and second segments of the duodenum tend to move up and seal the first hepatic hilar region through adhesions. Separate the adhesions downward along the visceral surface of the liver from the inferior liver margin and expose the gastric antrum and duodenum. Then, lower the gastric antrum and duodenum to further expose the CBD (Figure 4, Figure 5, and Figure 6).
5. Hepatic flexure of the colon: Separate the adhesions between the omentum, intestine, and abdominal wall of the right upper abdomen, and find the hepatic flexure of the colon. Separate and lower the hepatic flexure of the colon from the right inferior liver margin. Expose the CBD by separating the adhesions from the right subhepatic space to the omental foramen (Figure 3).

7. Sequential lithotomy

1. Laparoscopic lithotomy with forceps: Push the lower segment of the CBD using noninvasive grasping forceps, and squeeze the large stones toward the incision of the CBD. Take out the stones directly using forceps.
2. Laparoscopic lithotomy via blind basket extraction: Insert the stone basket into the CBD and open it. Then, pull the basket up and down repeatedly without choledochoscopic assistance. Take out the stones that cannot be squeezed toward the CBD incision via blind basket extraction, which substantially shortens the time of choledochoscopic lithotomy.
3. Stone removal by flushing the CBD with saline: Insert a silicone tube into the CBD. Use a 50 mL syringe to inject saline into the CBD through the silicone tube and flush out the small stones.
4. Choledochoscopic lithotomy: Insert the choledochoscope into the CBD, and continuously inject saline through the choledochoscope flushing channel. Put the stone extraction basket into the CBD through the instrument channel of the choledochoscope and open it, then take out the stones under the direct vision of the choledochoscope.
5. Lithotripsy: According to the diameter of the CBD, insert the sheath of the nephroscope of appropriate size into the CBD through the abdominal puncture port. Then, insert the nephroscope into the common bile duct through the sheath, and continuously inject saline.
   1. Perform pneumatic ballistic lithotripsy or holmium laser lithotripsy under the direct vision of the nephroscope.

8. T-tube indwelling or CBD primary suture

1. Primary suture the CBD for patients with a definite effect after lithotomy, a CBD diameter of ≥10 mm, and no evident stenosis of the lower segment of the CBD.

Representative Results

This study included 177 patients (mean age: 61.74 ± 5.97 years), including 79 males and 98 females. A total of 69 patients had a history of open cholecystectomy (OC); 36 patients had a history of OC and open common bile duct exploration (OCBDE); eight patients had a history of OC, OCBDE, and left lobe hepatectomy (LLH); three patients had a history of OC, OCBDE, and choledochojejunostomy; 42 patients had a history of laparoscopic cholecystectomy (LC); seven patients had a history of LC and LCBDE; and 12 patients had a history of LC and OCBDE (Table 1).

A total of 174 patients successfully underwent CBD exploration, and three patients were converted to laparotomy due to intraoperative hemorrhage of the CBD wall. The mean operation time was 163.72 ± 51.49 min. The mean intraoperative blood loss was 87.51 ± 32.93 mL. The mean time to first flatus was 28.94 ± 10.35 h. The mean postoperative drainage volume was 196.27 ± 46.26 mL. The mean length of hospital stay was 6.93 ± 2.68 days. The postoperative complication rate was 9.0%. There were three cases of postoperative bile leakage, one case of postoperative bleeding, five cases of residual stones, one case of abdominal infection, and six cases of incision infection (Table 2).

Figure 1: The parietal peritoneum and gastrointestinal serosa. Please click here to view a larger version of this figure.

Figure 2: The hepatic round ligament. Please click here to view a larger version of this figure.

Figure 3: The inferior liver margin and hepatic flexure of the colon. Please click here to view a larger version of this figure.

Figure 4: The gastric antrum and duodenum. Please click here to view a larger version of this figure.

Figure 5: The hepatic round ligament, inferior liver margin, and gastric antrum. Please click here to view a larger version of this figure.

Figure 6: The duodenum and CBD. Please click here to view a larger version of this figure.

Sex (n)
Male	79 (44.6%)
Female	98 (55.4%)
Age (years)	61.74 ± 5.97
History
OC	69 (39.0%)
OC+OCBDE	36 (20.3%)
OC+OCBDE+LLH	8 (4.5%)
OC+OCBDE+choledochojejunostomy	3 (1.7%)
LC	42 (23.7)
LC+LCBDE	7 (4.0%)
LC+OCBDE	12 (6.8%)

Table 1: Clinical features of the patients. OC = open cholecystectomy; OCBDE = open common bile duct exploration; LLH = left lobe hepatectomy; LC = laparoscopic cholecystectomy; LCBDE = laparoscopic common bile duct exploration.

Operation time (minutes)	163.72 ± 51.49
Intraoperative blood loss (mL)	87.51 ± 32.93
First flatus (hours)	28.94 ± 10.35
Postoperative drainage volume (mL)	196.27 ± 46.26
Hospital stay (days)	6.93 ± 2.68
Postoperative complications (n)	24 (9.0%)
Bile leakage (n)	3 (1.7%)
Bleeding (n)	1 (0.6%)
Residual stones (n)	5 (2.8%)
Abdominal infection (n)	1 (0.6%)
Incision infection (n)	6 (3.4%)

Table 2: Surgical outcomes of the patients.

Discussion

The most common cause of choledocholithiasis is stones falling into the CBD through the gallbladder, while some CBD stones can origin from the CBD itself¹. The incidence rate of choledocholithiasis in patients after cholecystectomy is 10%-18%, and 4%-24% of patients with choledocholithiasis have recurrence after the first lithotomy and often require repeated surgery(ies)^12,13. Since the first application of LCBDE in 1991, it has been proven to be safe and effective for the treatment of choledocholithiasis, and has been widely accepted and applied since the operation can be completed in one stage^14,15. Patients with a history of biliary tract surgery have different degrees of adhesions in the abdominal cavity and tissues around the liver, making the CBD difficult to expose, which increases the difficulty and risk of biliary tract reoperation and places high technical requirements on it. Hence, abdominal adhesions are considered a contraindication to laparoscopic surgery⁵. For patients with abdominal adhesions, conventional open surgery or ERCP combined with EST is often used in clinical practice^5,16. Conventional open surgery results in a large trauma and a long postoperative recovery time, while ERCP combined with EST is prone to cause complications such as hyperamylasemia, acute pancreatitis, gastrointestinal bleeding, gastrointestinal perforation, and retrograde biliary tract infection. As the function of Oddi's sphincter has received growing attention in recent years, endoscopic sphincterotomy of Oddi's sphincter can achieve partial preservation of Oddi's sphincter; however, this increases the difficulty of endoscopic lithotomy and can even lead to residual stones¹⁷.

With the increase in clinical demand and the development of laparoscopic technology, LCBDE has been applied in patients with a history of biliary tract surgery in recent years^18,19. However, the operation skills and procedures of LCBDE have not been standardized, since it has not been widely applied. Based on its surgical approaches and anatomical landmarks, this study summarized surgical experience with LCBDE into a programmed surgical operation procedure. First, a careful preoperative assessment must be carried out, with particular attention paid to the collection of medical history, physical examination, and imaging examination. The past medical history and physical examination include the cause of the disease spurring the previous surgery, the number of surgeries, the surgical method(s), the time of the last surgery, and the condition of the previous surgical incision. These are all important factors for evaluating the severity of abdominal adhesions and provide key guidance for reoperation. The more previous surgeries the patient has had, the more severe the degree of abdominal adhesions will be. Abdominal adhesions after previous open surgery are more severe than those after laparoscopic surgery, and abdominal adhesions after previous open biliary tract surgery are more severe than those after cholecystectomy. The longer the time since the last surgery, the more stable the scar adhesions will be and the less severe the adhesions will be. A longer previous surgical incision will have more severe adhesions. The adhesion of a previous longitudinal incision in the upper abdomen is less severe than that of a previous oblique incision on the right subcostal margin. Second, routine abdominal CT and MRCP examinations are recommended before surgery. Imaging evaluation has very high sensitivity and specificity in the diagnosis of choledocholithiasis. Abdominal CT and MRCP can visually display the diameter of the CBD, the number of stones, the sizes of the stones, and the locations of the stones. Therefore, the changes in the anatomical structure due to previous surgery can be understood, and the operation difficulty and possible difficulties can be evaluated.

At the beginning of the surgery, when pneumoperitoneum is established and the first trocar is punctured, the incision should be kept as far away as possible from the original surgical incision. Generally, the first trocar should be placed more than 5 cm away from the previous open incision, or more than 2 cm away from the laparoscopic incision. to avoid abdominal adhesions. The arrangement of the trocars needs to be comprehensively considered. They can be put in one by one after the abdominal wall adhesions are released, two large and two small trocars can facilitate the insertion of the laparoscope from different angles for operation, and an additional operation port can be introduced if necessary.

Adhesion separation and CBD exposure are the critical steps in the procedure. For patients with extensive abdominal adhesions, a standardized operation protocol is lacking. By analyzing and summarizing the experience, a programmed operative procedure based on anatomical landmarks is proposed. In short, four surgical approaches can be used, the hepatic round ligament approach, the anterior hepatoduodenal ligament approach, the right hepatoduodenal ligament approach, and the hybrid approach. Given the differences in the range and extent of abdominal adhesions after different surgical procedures, the hybrid approach is recommended, which can be flexibly applied according to the specific intraoperative conditions. These surgical approaches are based on several key anatomical structures, including the parietal peritoneum, gastrointestinal serosa, hepatic round ligament, inferior liver margin, gastric antrum, duodenum, and hepatic flexure of the colon. The adhesions between the greater omentum and the abdominal wall are separated close to the parietal peritoneum, to minimize damage to the omental blood vessels and reduce the risk of bleeding. The adhesions between the gastrointestinal tract and the abdominal wall are separated under appropriate traction tension, close to the parietal peritoneum and away from the gastrointestinal serosa to best avoid gastrointestinal injury. Gastrointestinal injury occasionally happens during adhesion separation; this should be repaired immediately, to avoid adverse consequences caused by forgetting to repair the injury after surgery. Excessive separation of areas that do not affect the surgical procedure should be avoided. If it is difficult to complete the separation and exposure of extensive adhesions under laparoscopy, the operation should be converted to laparotomy in a timely manner. The hepatic round ligament is a useful anatomical landmark. During the operation, attention should be given to the identification of the hepatic round ligament, as long-term adhesion and compression makes the hepatic round ligament flat. The adhesions should be separated, following the hepatic round ligament upward till the inferior liver margin. If the diaphragmatic surface of the liver adheres to the abdominal wall, an obtuse angle is formed between the visceral surface of the liver and the abdominal wall. When the inferior liver margin is found, the adhesion between the diaphragmatic surface of the liver and the abdominal wall does not need to be separated, or can be separated later. This is because the adhesion at this location plays the role of a natural retractor, which helps to expose the hepatic hilum by hanging the liver. At this time, the separation is continued near the visceral surface of the liver to further loosen the adhesions between the gastric antrum and the first and second segments of the duodenum and the hepatic hilar area, thereby lowering the gastric antrum and the duodenum and exposing the CBD. In addition, the surgeon can also lower the hepatic flexure of the colon through the right inferior liver margin to separate the adhesions from the right lateral to the medial side of the subhepatic space, thereby exposing the right wall of the CBD.

The clues to identify the CBD include a previous surgical suture knot or a titanium clip, a cystic duct stump, adhesions formed by the original T-tube sinus tract, palpable hard stones or a cord-like internal stent, bile or biliary sludge from a fine-needle puncture, intraoperative endoscopic ultrasound, and indocyanine green fluorescence. Because recurrent choledocholithiasis often involves multiple stones, the direct use of a choledochoscope for lithotomy often prolongs the operation time. Therefore, sequential lithotomy can help shorten the lithotomy time. Large stones exposed after a longitudinal incision of the CBD can be directly removed. Even stones in the lower segment of the CBD can be moved upward into the CBD incision by squeezing the lower segment of the CBD or the duodenum, and then removed from the incision. After some stones are removed under direct laparoscopic vision, a gap appears in the CBD. At this time, the lithotomy basket can be directly inserted into the lower segment of the CBD under the laparoscope to extract some of the stones. After the first two steps, the silicone tube can be inserted into the lower segment of the CBD and flushed with normal saline to take the fragmented stones out of the CBD. Finally, the choledochoscope is inserted into the CBD, and the remaining stones are removed through basket extraction. Sometimes, stones may be incarcerated in the lower segment of the CBD or the duodenal papilla; these incarcerated stones are difficult to remove through basket extraction. Such stones can be fragmented by pneumatic ballistic lithotripsy or holmium laser lithotripsy under a nephroscope. A growing number of reports have suggested that primary suture of the CBD is feasible and safe^20,21. Most of the patients in this study underwent primary suture of the CBD and got excellent results. However, in a few cases, there are still indications for placing a T-tube for drainage, such as elderly patients and patients with many stones, suspected residual stones, edema and stenosis of the lower CBD, or severe bile duct inflammation. For elderly patients, their physical conditions may be difficult to bear the risk of the potential complication of postoperative bile leakage. For patients with multiple stones or even suspected residual stones, T-tube drainage reserves a sinus for future choledochoscopy. For patients with severe cholangitis, there is often edema in the lower part of the CBD, and T-tube retention is helpful to drain the bile and improve biliary obstruction.

This study proposed surgical approaches and key anatomical landmarks for LCBDE in patients with a previous history of biliary tract surgery, and summarized the procedure into a programmed operation. The procedure, based on these surgical approaches and key anatomical landmarks, is generally applicable to patients who have undergone different surgical methods previously, including OC, OCBDE, LC, LCBDE, and choledochojejunostomy. The limitation of this technique is that it is difficult to completely deal with superior intrahepatic bile duct stones. In conclusion, the mastery of these surgical approaches and key anatomical landmarks can improve the safety of LCBDE in patients with a history of biliary tract surgery, promote rapid recovery, reduce postoperative complications, shorten the learning curves of surgeons, and further promote the application of laparoscopic techniques in patients with a history of biliary tract surgery for re-exploration of the biliary tract.

Materials

Name	Company	Catalog Number	Comments
Electronic choledochoscope	Olympus	CHF-V	/
Harmonic scalpel	Ethcion	HAR36	/
Stone basket	Cook	NTSE-045065-UDH	/