Laparoscopic Common Bile Duct Exploration With Primary Closure After Failed Endoscopic Retrograde Cholangiopancreatography Without Intraoperative Cholangiography: A Case Series from a Referral Center in Bogota,Colombia

Abstract

Background:

Despite the effectiveness of laparoscopic common bile duct (CBD) surgery, no case series details the use and advantages of laparoscopic CBD exploration (LCBDE) without use of intraoperative cholangiography (IOC) in endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we present a case series regarding our success with LCBDE in managing CBD stones (CBDSs) using laparoscopic technique without IOC.

Materials and Methods:

We performed a descriptive retrospective observational study. Patients with CBDSs, alone or along with gallbladder stones, were treated through LCBDE with primary CBD closure after failed ERCP.

Results:

All patients underwent LCBDE with choledocotomy and primary duct closure. Patients with gallbladder stones underwent laparoscopic cholecystectomy (78%). All procedures were successful, and no conversions occurred. Surgery duration averaged 106 minutes. Intraoperative bleeding averaged 15 cc, and no mortalities occurred. No patients required additional surgery or intensive care unit admission. Hospitalization duration averaged 5 days.

Conclusions:

Therefore, a laparoscopic approach with primary CBD closure after failed ERCP for complex CBDSs is safe and effective.

Introduction

In the field of surgery, the common bile duct (CBD) exploration using minimally invasive techniques is an important issue due to the technically complex use of laparoscopy.^1–3 Currently, benign CBD pathologies, primarily CBD stones (CBDSs), are mostly handled through open surgery and endoscopic approaches. With the advent of new minimally invasive techniques and technologies, the laparoscopic surgical management of CBDSs has emerged as a safe and effective alternative.^4–7 Even in emergency cases, laparoscopy has shown to be superior to endoscopy in managing CBDSs.^8,9

However, despite worldwide studies showing the effectiveness of laparoscopic CBD surgery, there is no current consensus detailing the use and advantages of laparoscopic CBD exploration (LCBDE), nevertheless, laparoscopic surgery has shown to have less invasion and fast recovery. Therefore, we present a case series regarding our success in the management of CBDSs using a three-port laparoscopic approach.

Materials and Methods

Study design

We conducted a descriptive retrospective observational study of patients with CBDSs, who were treated through LCBDE with primary CBD closure after failed endoscopic retrograde cholangiopancreatography (ERCP) at our center in Bogota, Colombia between February 2013 and November 2018.

The database from a tertiary referral center in Bogota, Colombia, which is specialized in the laparoscopic management of gastrointestinal disorders, was reviewed to collect and analyze patients' data and characteristics. These data included age, sex, patients' clinical presentation of CBDSs, the time between patients' first clinical approach and LCBDE, preoperative workup results (clinical evaluations and biochemical and hematological tests), causes for failed ERCP (Table 1), operation time, the amount of bleeding, bile leak occurrence, intensive care unit (ICU) admission, length of hospital stay, residual CBDS occurrence, reintervention, and mortality.

Table 1.

Reason for Failed Endoscopic Retrograde Cholangiopancreatography Extraction

Stones >1.5 cm in diameter	26	32.4%
Remaining stones after multiple endoscopic attempts	21	25.8%
Multiple stones combining dilated bile duct (diameter >1.5 cm)	17	20.8%
Impacted stones	12	15.3%
Yuxtapapilar diverticulum	5	5.4%
TOTAL	82	100%

All patients had the surgeon's email and cell phone number, to ensure strict follow-up and not lose the continuity of clinical surveillance.

The study protocol was approved by our institution's ethics committee. The protocol was implemented in accordance with the provisions of the Declaration of Helsinki and Good Clinical Practice guidelines.

Inclusion criteria

These involved patients >18 years of age, diagnosed with CBDSs who were taken to LCBE with primary closure after a failed ERCP without intraoperative cholangiography (IOC).

Exclusion criteria

These involved patients with malignant biliary obstructive pathology (periampullary tumors), exhibiting extrinsic compression of the bile duct due to any cause, bile duct injury, acute or chronic malnutrition, noncontrolled intra-abdominal or systemic infections, biliary liver cirrhosis child pugh B or more, hemodynamic instability, active cholangitis and contraindication of pneumoperitoneum.

Statistical analysis

Due to the observational nature of the study, we only performed a descriptive analysis of the data from prospective Microsoft Excel databases using SPSS 1 (Statistical Package for The Social Sciences) version 22.0. Continuous variables are presented as “mean (range).”

Surgical technique

Patient preparation

Patients were prepared for LCBDE as they would have been for an open operation. First, the referral institution called us to present us with patients. Second, in the emergency room, we evaluated the patients' hemodynamic status. Patients and their families were informed of the risk of bowel injury, the possible need for additional trocars, the risk of conversion, and the risk of morbidity and mortality associated with this kind of surgery.

Equipment, room, and surgery setup

Before surgery, patients underwent magnetic resonance cholangiography (MRCP) to identify the number and location of CBDSs. The protocol for MRCP consists of fast sequences in T2 (half-Fourier acquisition single-shot turbo spin-echo [HASTE] Siemens Medical Solutions) in axial and coronal planes, with and without fat suppression (FS-Fat Sat) of 5 mm, colangio T2 thick slab 50 mm and thin slab 4 mm (20 cuts), colangio T2 thick slab 50 mm and thin slab 3 mm (17 cuts) and dynamic cholangiography in train of 10 cuts every 12 seconds.

All the patients received prophylactic first-generation cephalosporin. In preparation for surgery, patients were placed in the supine position with both arms tucked along their sides and pneumatic stockings were applied, all under general anesthesia. Patients were then securely strapped to the surgical bed to facilitate the maximum tilting and lateral rotation of the operating table in French position. Next, to the surgeon, the first assistant proceeded to stand on opposite sides of the table. The surgical team would move around the patient in accordance with operative findings. Then, the surgeon moved to the patients' left side to prepare for cholecystectomy. At this point, the first surgical assistant stood at the right of the surgeon and the scrub nurse to the right of the first assistant.

Laparoscopic CBD extraction

First of all, at the surgical planning, it is important to keep in mind that patients who did not have a previous history of laparoscopic cholecystectomy could use the same with a repair point for bile duct management. In patients with a history of cholecystectomy without another surgical history, conventional technique was used to perform the bile duct exploration. The above will define the number of additional ports that are required for surgery. Hasson's open technique is used for the insertion of the 12 mm optical trocar above the umbilicus, and CO₂ insufflation at a pressure of 12 mm Hg for the creation of pneumoperitoneum maintaining an adequate intra-abdominal pressure. A 30° laparoscope is used. The manipulation trocars are placed to the right and the left of the laparoscope, as shown in Figure 1.

FIG. 1.

Trocars position.

Under direct vision, a right upper quadrant trocar was placed for dissection of the CBD. A third and last trocar was placed under direct vision at the left paramedial port site in the left upper quadrant and used for the insertion of a grasper or an irrigation-lavage device.

Using a single Prolene 2-0 (Ethicon, Inc., Cincinnati, OH) suture, the gallbladder was elevated from the gallbladder fundus and held against the abdominal wall in the right upper quadrant, thereby exposing Calot's triangle as shown in Figure 2.

FIG. 2.

Gallbladder suspension for exposing Calot's triangle.

Using sharp scissors and hook, the triangle of Calot was dissected, thereby revealing the critical view. Once the porta hepatis and inferior hepatic surface were exposed, the dissection of the common hepatic duct and CBD was performed while taking care not to devascularize the CBD.

Vertical choledochotomy of ∼10–20 mm incision was made in the anterior aspect of the CBD, using the hook and low diathermy to reduce dispersion energy and bleeding from the CBD walls and avoid losing the surgical field with minimal energy dispersion, as shown in Figure 3.

FIG. 3.

Choledocotomy.

CBDSs were then directly extracted using laparoscopic dissector, followed by a proximal and distal bile duct lavage using a 16–20-F Nelaton tube to apply 20–50 cc of normal saline solution until clear fluid was observed. The last step of this lavage was done using a Fogarty catheter size 4–5F, as shown in Figures 4 and 5.

FIG. 4.

Bile duct lavage with a Nelaton tube.

FIG. 5.

CBD exploration using a Fogarty catheter. CBD, common bile duct.

After the extraction of all CBDSs, primary CBD closure was done using laparoscopic simple interrupted PDS 4-0 (Ethicon, Inc.) sutures. Next, the gallbladder portion of the surgery was done by clipping the cystic artery and duct using titanium clips (three clips per structure). Afterward, laparoscopic cholecystectomy was performed through a cystic-fundus technique with a hook. The fundus-abdominal wall suture was cut and, using an Endo-catch, the gallbladder was extracted through the left paramedial port site. The abdominal cavity was then drained and checked for bleeding, as shown in Figure 6.

FIG. 6.

Primary closure of common bile duct.

Next, a peritoneal passive drain was placed in the supramesocolic space through the right upper quadrant port site. Finally, trocars were extracted under direct vision, pneumoperitoneum was evacuated, abdominal fasciae were closed using simple interrupted PDS 0 (Ethicon, Inc.) sutures, and skin was closed using Prolene 3-0 (Ethicon, Inc.) sutures.

Discharge and follow-up

Patients were discharged once their peritoneal drains were removed. Follow-up assessments involving ultrasound examinations were carried out at the outpatient clinic within 24 months after discharge. If the ultrasound examination demonstrated possible residual stones, MRCP or ERCP was carried out to investigate further. No patients experienced pancreatitis, or retained or recurrent stones, bile duct stricture or cholangitis during a mean follow-up period of 24 months.

Results

From February 2013 to November 2018, 82 CBDS patients who underwent LCBDE with primary CBD closure after failed ERCP were included in our study. Of these 82, 65% were women and 35% were men, as shown in Table 2. The most common cause of failed ERCP was having CBDSs >1.5 cm. All patients underwent LCBDE with choledocotomy and primary duct closure. Patients with gallbladder stones underwent laparoscopic cholecystectomy (78%) at the same surgical time. All procedures were successful and no conversions occurred.

Table 2.

Sociodemographic Characteristics

Sociodemographic characteristics
	n
Age years (min–max)	47 (47–91)
Gender
Female (%)	65
Male (%)	35
Comorbidities
Patients with comorbidities	26
BMI >30	14
Surgical characteristics
Bile duct caliber (mm)	11 (10–13)
Obstructive jaundice	75
ASA classification
I (%)	29
II (%)	39
III (%)	14

In terms of surgery results, surgery duration averaged 106 minutes, intraoperative bleeding averaged 15–50 cc, no mortalities occurred, and no patients required ICU admission.

A patient, 40 months later, presented recurrent choledocolithiasis due to juxtapapillary diverticulum, managed with the same surgical technique and resolved without complications. One patient had a biliary leak that was managed with a stent and evolved well, as shown in Tables 3 and 4.

Table 3.

Surgical Variables

Variables quirugicas	n	%
CBD explorations with choledocotomy, primary duct closure	82	100
Cholecystectomy	64	78
Surgical time (minutes, min–max)	106 (100–130)
Number of CBDSs removed	2.8 (2–4)
Operative bleeding (mL)	15–50
Procedures using a laparoscopic approach	82	100

CBDS, common bile duct stone.

Table 4.

Surgical Outcomes

Surgical outcomes	n	%
T tube (%)	0	0
Re-intervention (%)	0	0
ISS
Superficial SSI	1	1.2
Deep SSI	0	0
Bile leak (n)	1	1.2
Need for CBD re-exploration (n)	1	1.2
Non per os (days)	1
ICU (days)	1–5
Hospital stay (days)	2–6
Mortality	1	1.2
Postoperative strictures	0	0
Stone recurrence	0	0
Maximum follow-up (year)	1

CBD, common bile duct; ICU, intensive care unit.

Patients >75 years (30%) with >3 comorbidities were taken to the ICU for 1–2 days for clinical surveillance.

One patient died, after the procedure he had COPD decompensation and heart failure at five POP days, secondary to pneumonia.

Within the follow-up, 7 patients >80 years died due to decompensation of their underlying pathology, on average 2 and 3 years after the intervention, it was not considered a relationship between death and surgical intervention.

Discussion

To our knowledge, ours is the largest case series in Latin America and the first of its kind to report on benign CBD pathologies treated through laparoscopy with primary CBD closure and previous MRCP, without the need for IOC and choledocoscopy, which result in no residual CBDSs. We take advantage of the high sensitivity and specificity that MRCP can offer in diagnosing and locating CBDSs, as seen in a recent meta-analysis performed by Meeralam et al., because our institution does not have choledocoscopy resources. In terms of patients with CBDSs, initial and single-step laparoscopic surgery allows surgeons to avoid standard endoscopic CBD drainage followed by gallbladder removal.^10,11 Despite this, due to technical complexity of laparoscopic approach, it is not an established standard approach.²

Our case series shows a 97% success rate with no conversion, which is superior to the results of Gigot et al.¹² who reported a laparoscopic CBDS clearance rate of 84% (transcystic approach, 63%; choledochotomy, 93%) and a 12% and 5% rate of patients converting to laparotomy because of incomplete stone clearance and intraoperative complications, respectively. The Gigot et al. study also had long surgical times and used T tubes, unlike us.¹² Our results were also superior to those of Salama et al. who performed 129 LCBDEs and reported a successful laparoscopic CBDS clearance rate of 123/129 (95.4%) (transcystic approach, 103 patients; choledochotomy, 26 patients).¹³ Moreover, Salama et al. only had 7 patients who underwent primary CBD closure, whereas they used T tubes and antegrade stents for CBD closure in 9 and 10 patients, respectively.¹³ In our study, we were able to decrease surgical times by not having to perform IOC or choledocoscopy due to using MRCP to count and locate CBDSs. Other reports also show similar results to ours, and highlight the advantages and benefits of using laparoscopy for these types of CBD pathologies.^7,8,14,15

In our study, we provide a novel technique involving primary CBD closure after LCBDE without the use of T tubes. In a systematic review and meta-analysis by Podda et al., 1770 patients underwent primary CBD closure without T tube placement with a significant P value. Podda et al. also showed that primary CBD closure without T tubes has benefits, including lower rates of bile leaks, less surgery time, and quicker discharge times. Other studies have also shown similar advantages when primary CBD closure is implemented.^16–19

The more frequent approach for the management of benign CBD pathologies, like CBDSs, is a two-stage procedure involving endoscopic sphincterotomy and CBDS removal, followed by laparoscopic cholecystectomy. Another option for the management of gallbladder stones and CBDSs is laparoscopic–endoscopic rendezvous, which combines endoscopic sphincterotomy and laparoscopic cholecystectomy in a single-stage operation.²⁰ In 2017, Vettoretto et al. performed a systematic review and meta-analysis of five randomized clinical trials with 517 participants. Of these 517, 257 underwent laparoscopic-endoscopic rendezvous and 260 underwent the sequential approach.²⁰ Only one death was reported in the laparoscopic–endoscopic rendezvous group. The overall morbidity may have been lower in the laparoscopic–endoscopic rendezvous, but there was insufficient evidence to determine the effects of either approach on the failure of primary bile duct clearance because the laparoscopic–endoscopic group's length of hospital stay was lower than the sequential approach group's by 3.51–2.50 days. However, the laparoscopic–endoscopic rendezvous group required longer operation times in comparison with our experience.

ERCP is still the best initial approach for CBDS treatment. However, in cases when stone extraction by ERCP is not possible, a single intervention done by experts may decrease adverse risks to patients. Among the novelties of our case series, we highlight the use of single-procedure LCBDE with primary CBD closure, thereby avoiding the traditional use of T tubes and cholecystectomy. Our method uses a three-port approach in some cases, technique that yields similar results to traditional laparoscopic techniques without any variations in intraoperative bleeding or complications. In addition, a single surgery offers clear advantages to patients, such as allowing for a quicker return to daily activities, fewer days spent in the hospital, and fewer complications.²¹ Another advantage of LCBDE is the preservation of the Oddi sphincter and avoiding complications secondary to endoscopic manipulation, such as stenosis and future stone formation.¹⁷ Although there are no significant differences between using a three-port approach and traditional laparoscopy for CBDS treatment, the three-port approach seems to be a safe and effective method that provides similar results to traditional laparoscopy while causing less trauma to patients and being esthetically superior. It is important to highlight that adding a fourth port or converting to open surgery should not be considered a surgical failure.^22–24 Success rates with three-port laparoscopic cholecystectomy reach 90% in most case series, while in this series, with both approach (three-port and conventional) the success rate was 100%, allowing for a more rapid return to daily activities by resulting in an average of 1–2 fewer days in the hospital when compared with other studies.¹⁹ Furthermore, our single-procedure three-port laparoscopic approach shows results similar to approaches involving traditional ERCP followed by laparoscopic gallbladder removal performed using two separate procedures. The choice approach in terms of CBDS treatment depends on patient status, surgeon experience, and equipment availability.²¹ The main limitation of this study is that it is an observational retrospective study without randomization and no control group. It is, therefore, subject to selection bias.

Conclusions

In terms of treating complex CBDSs, a single-procedure laparoscopic approach with primary CBD closure after failed ERCP and MRCP for identifying and locating CBDSs, along with no use of IOC for confirmation, is safe, effective, and provides patients with quicker recovery and discharge times and few complications, whenever performed by an experienced surgeon. However, high-level clinical studies are required to establish the effects of not carrying out routine choledocoscopy or IOC at the end of LCBDE.

Footnotes

Acknowledgment

We thank Editage for English language editing.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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