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Laparoscopic common bile duct exploration 腹腔鏡總膽管探查術

Laparoscopic common bile duct exploration 腹腔鏡總膽管探查術. 奇美醫學中心　溫義輝. Introduction. Biliary T-tube after choledochotomy Advantage: for decompression / cholangiography / retrieval of retained stone

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Laparoscopic common bile duct exploration 腹腔鏡總膽管探查術

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  1. Laparoscopic common bile duct exploration腹腔鏡總膽管探查術 奇美醫學中心　溫義輝

  2. Introduction • Biliary T-tube after choledochotomy • Advantage: for decompression / cholangiography / retrieval of retained stone • Disadvantage: high complication rate (15.3%)*, technical requirement (laparoscopic T-tube placement and suturing) *ANZ J of Surgery 2002

  3. Purpose • Retrospective comparison of the results of laparoscopic versus open choledochotomy to seek methods of prevention of T-tube related complications and check the strategy of T-tube free approach.

  4. Material and Methods • Indication for laparoscopic choledochotomy • Stone not suitable TCyD approach (CHD stone, stone large than CyD, CyD-CBD junction prevent easy access to the CBD) • CBD diameter > 8mm • CBD stone number < 10 • Contraindication for laparoscopic choledochotomy • Large / impacted / too many stones in CBD (CHD) • s/p exploratory laparotomy

  5. Procedures of laparoscopic choledochotomy • LC with routine use of IOC • Choledochotomy: electrical cauterization (fine needle / low electric diathermy current) • Choledocholithotomy: choledochoscopy (EHL) • Placement of T-tube: tailored T-tube with split arm • Suturing of CBD • Transfixing sutures (3-0 plain catgut) • Completion cholangiography if indicated

  6. Result (I)

  7. Result (II)

  8. Result (III)

  9. Outcome of biliary complication after laparoscopic choledochotomy

  10. Discussion(I) • In this study, almost laparoscopic choledochotomy were successfully completed, but there were significantly higher incidence of retained stones and T-tube related complication.

  11. Discussion(II) • In case needing T-tube drainage, the technique of choledochotomy and T-tube placement should be familiarized (including incision of small caliber CBD, indwelling o tailored T-tube with split arm and fixation of T-tube), and the quality of T-tube should be properly selected (Latex > Silicon).

  12. Discussion(III) • In case suitable for T-tube-free laparoscopic choledochotomy, stone clearance should be aggressively attempted and definitely confirmed by thorough choledochoscopic examination and standard completion cholangiography.

  13. Conclusion • Single stage laparoscopic choledochotomy, including laparoscopic cholecystectomy and choledocholithotomy is feasible and safe for patients with CBD stones. • T-tube related complications should be prevented in laparoscopic choledochotomy with T-tube drainage procedures and duct clearance should be confirmed in T-tube free procedures.

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