Laparoscopic-cholangioscopic cooperative modified tunnel technique for hepatolithiasis combined with dilated common bile duct: A case report and literature review

Abstract

Introduction

Intrahepatic and extrahepatic lithiasis, a condition characterized by the presence of stones in the liver and bile ducts, is a common disease in Asia, particularly in East and Southeast Asia. We report a case with laparoscopic exploration of the common bile duct using a flexible cholangioscope and modified trans-common bile duct tunnel for hepatolithiasis combined with the dilated common bile duct.

Presentation of case

A 35-year-old male patient has had chronic epigastric and right upper quadrant pain. The common bile duct was 11 mm dilated, and hepatolithiasis was also present, according to an upper abdomen MRI. The largest stone measured between 14 and 21 mm. A modified trans-common bile duct tunnel from the abdominal wall into the common bile duct was used in a laparoscopic procedure to examine the common bile duct. Complications during the procedure or following it were not present. The procedure took 120 min, and the blood loss was about 50 ml. The patient was discharged on the sixth postoperative day, and a follow-up visit one month later revealed that single-session stone clearance had been accomplished.

Discussion

Laparoscopic exploration of the common bile duct using a cholangioscope and modified trans-choledochal tube is applicable in selected patients and can be effectively and safely used to treat hepatolithiasis combined with the dilated common bile duct.

Conclusion

In this case, we present an innovative approach for hepatolithiasis when combined with dilated common bile duct.

Highlights

• •Intrahepatic and extrahepatic lithiasis are common in East and Southeast Asia.
• •Modified trans-choledochal tube utilizing ShileyTM Hi-Lo Cuffed endotracheal tube
• •Lap CBD exploration is suitable for treating hepatolithiasis with dilated CBD.

1. Introduction

Intrahepatic lithiasis and extrahepatic lithiasis, commonly known as biliary stones, are common in East and Southeast Asia [1]. Treatment choice depends on stone location, severity, and patient health. Hepatectomy is typically considered when there are large or multiple intrahepatic gallstones that cannot be effectively managed through other techniques. Hepatectomy is a more extensive procedure and is associated with a longer recovery period. Choledochostomy is commonly used for the treatment of extrahepatic lithiasis. A combined laparoscopic-cholangio approach allows direct visualization and stone removal, with T-tube insertion if needed. Bilioenteric anastomosis may be considered when there is a significant obstruction, or other treatment options are not feasible.

It is important to note that strategy treatment should be tailored to the patient's condition and medical expertise. The introduction of laparoscopic and endoscopic techniques has expanded the treatment options for gallstones, including combined laparoscopic-cholangioscopy, often preferred due to its minimally invasive nature. This approach allows for direct visualization and stone removal from both the gallbladder and bile ducts [2].

However, there is an ongoing debate and no consensus on the optimal treatment approach for intrahepatic stones associated with a dilated common bile duct. We propose a new minimally invasive technique using a cholangioscope and modified transcholedochal tube via laparoscopic bile duct exploration. The case report follows SCARE criteria [3].

2. Presentation of case

A 35-year-old male patient was experiencing chronic epigastric and right upper quadrant pain. A magnetic resonance cholangiopancreatography revealed hepatolithiasis combined with a dilated common bile duct measuring 11 mm in diameter. The largest stone detected had dimensions of approximately 14 mm × 21 mm (Fig. 1). Based on the provided information, the preoperative diagnosis is hepatolithiasis combined with a dilated common bile duct (CBD).

Fig. 1.

MRCP shows intrahepatic stones and dilated CBD.

Laparoscopic CBD exploration was performed, followed by the use of electrohydraulic lithotripsy. We accessed the abdominal cavity using the Hasson technique to place the camera port at the umbilical. Two working ports (5 mm) were placed at bilateral hypochondriac regions. The final working port (10 mm) was placed 2 cm below the right costal margin on the midclavicular line and utilized to set the modified trans-choledochal tunnel (Fig. 2). After exposing the CBD, we placed two stay sutures between the abdominal wall and edges of the CBD and performed choledochotomy on the CBD's anterior wall (Fig. 3A). After that, we inserted a modified trans-choledochal tunnel through the fourth working port (Fig. 3B). This tunnel serves as a secure passage for stone fragments and prevents their entry into the abdomen.

Fig. 2.

Trocars' position.

Fig. 3.

A modified trans-choledochal tunnel: (A) The modified trans-choledochal tube was inserted into the CBD through the fourth working port; (B) the cholangioscope passed through the modified trans-choledochal tube.

The surgical team modified the Shiley™ Hi-Lo Cuffed endotracheal tube by replacing the standard connector with a Shiley™ double swivel connector, creating two channels for the cholangioscope (channel 1) and suction system (channel 2). We also utilize the above cuff suction port (channel 3) as an irrigation system (Fig. 4). These devices are likely used to assist with the surgical manipulation and visualization of the CBD during the procedure. In this case, we use the 10-mm diameter endotracheal tube and do not inflate the cuff because the CBD is 11 mm in diameter and is nearly fixed with the tube.

Fig. 4.

The modified transcholedochal tunnel.

The endoscopic assessment showed hepatolithiasis, which is consistent with the preoperative diagnosis (Fig. 5). Electro-hydraulic lithotripsy is used to fragment biliary stones. The stone extraction baskets typically have a flexible wire structure with a mesh or basket-like end that can be opened and closed to trap and retrieve the stone fragments. Irrigation of the CBD is performed to help flush out the fragmented stone particles and any remaining debris from the duct. It involves the introduction of sterile fluid into the CBD through an instrument or catheter to ensure the duct is clear of any residual stones or debris.

Fig. 5.

Endoscopic images of intrahepatic stones.

A T-tube is inserted into the CBD at the end of the surgery to facilitate bile drainage and assess the duct's patency. Intraoperative blood loss was 50 ml. We checked routinely complete blood count and serum biochemistry tests on postoperative days 1, 3, and 5. These tests did not reveal any evidence of biliary blockage or sepsis, and he was discharged on postoperative day six. The one-month follow-up ultrasound revealed clearance of the stones and a patent biliary system, so we removed the T-tube.

3. Discussion

In the past, the standard procedure for removing biliary stones was choledochotomy through an open surgery [4]. Since the 1970s, per-oral cholangioscopy (POC) with conventional sphincterotomy has been a commonly used procedure for bile stones removal. According to Carr et al. [5], this approach has a success rate of over 85 %. However, there are anatomical variations where standard POC may be challenging, such as a difficult bile duct size, sigmoid shape, low take-off, or diverticulum periampullary at a stricture [6,7]. In these cases, alternative approaches may need to be considered to overcome the challenges and successfully remove the stones. Chen and Draganov report a successful clearance rate of extrahepatic stones ranging from 71 % to 100 % when utilizing POC combined with intraductal lithotripsy [8,9]. In a retrospective cohort investigation involving 107 patients with biliary stones, 91 % experienced clearance when POC was used. However, complete stone clearance typically required multiple sessions, with an average of 3 sessions (range: 1–6). The study also noted that complete stone removal occurred in only 39.3 % of cases during the first session. This suggests that repeat sessions may be necessary to achieve complete clearance of stones using POC [10]. Using per-oral “Mother-baby” video cholangioscopes can help improve the control capacity of the scope during cholangioscopy. This technique involves using a “baby” cholangioscope inserted through the operating channel of a specially designed therapeutic duodenoscope (the “mother” duodenoscope). This allows for better maneuverability and visualization during the procedure [11]. The study by Okugawa et al. [12] involved a case series of 36 patients with intrahepatic duct stones reported a full hepatolithiasis removal rate of 64 %. While this technique showed a moderate removal rate, it suggests a potential treatment option for intrahepatic duct stones. The use of per-oral cholangioscopy has its limitations and challenges. These include high treatment expenses, fragility of the cholangioscope, the need for two qualified endoscopists, limited capacity for tip deflection, and insufficient irrigation capacity. These factors may affect the widespread use and applicability of the technique [8,9,13],

Another approach mentioned is percutaneous cholangioscopy, which involves the insertion of a specialized endoscope through the skin and into the bile ducts. The comprehensive series involving 190 patients reported a higher full clearance rate of hepatolithiasis, achieving 88.4 % success [14]. This technique provides direct visualization and the opportunity for better stone clearance.

Cholangioscope-assisted laparoscopic exploration of CBD allows direct visualization and management of the biliary ductal system, which is essential for identifying biliary strictures and managing challenging biliary stones. However, specific challenges are associated with this procedure, particularly regarding intrahepatic stone removal and the risk of postoperative complications. The complexity of accessing and manipulating intrahepatic stones makes the procedure time-consuming and challenging. Intraoperative stone fragments and bile leakage increase the risk of the surgical site and intra-abdominal infections. Proper measures must be taken to minimize the risk of infection, including maintaining a sterile environment and ensuring adequate drainage and closure of the biliary system.

A percutaneous-choledochal tube was described by Le et al. [2]. However, this device was reported to have limitations such as a lack of multiple operator channels, closed suction and irrigation system, and a limited range of diameters suitable for different biliary tract dilatations. Based on the described method, we innovated an improved instrument utilizing ShileyTM Hi-Lo Cuffed endotracheal tubes with multiple manipulative working gates. The modified trans-common bile duct tunnel helps to create a controlled and sealed passage for the cholangioscope and other instruments.

The instrument features a one-way closed suction and irrigation system, which helps to facilitate the removal of debris and irrigation of the CBD during the procedure. Maintaining a closed system reduces the potential for contamination and complications related to spillage. The horizontal shape of the suction tube helps prevent the CBD from collapsing, ensuring continuous access to the biliary system. A balloon is incorporated into the instrument to maintain stability within the CBD. This feature provides a stable platform for the cholangioscope, enhancing the surgeon's control and maneuverability during the procedure. This stability is crucial for precise visualization and manipulation of instruments, ultimately contributing to the successful removal of stones. The instrument offers a wide range of diameters to accommodate the varied dilatations of the CBD. This flexibility allows for optimal fitting and maneuverability within the biliary system. In this case, we used the 10-mm diameter endotracheal tube and did not inflate the cuff because the CBD is 11 mm in diameter and was nearly fixed with the tube. However, we inflate the cuff for more dilated CBD until there is no water spilled out when we irrigate the CBD. The flexible cholangioscope is then inserted through this tunnel, which has been inserted through the abdominal wall into the CBD. This approach allows for direct visualization and manipulation of the biliary stones using the cholangioscope. The procedure outlined in the report seems effective in cases where the CBD has a diameter of more than 8 mm. This is important because it allows the insertion of the trocar diameter required for the endoscopic lithotripsy tunnel. The laparoscopic approach minimizes tissue trauma compared to traditional open surgeries. Using techniques such as electro-hydraulic lithotripsy and stone extraction baskets further reduces tissue injury during stone removal.

By addressing these specific concerns, the modified trans-common bile duct tunnel enhances the overall safety and efficacy of the laparoscopic approach for hepatolithiasis combined with dilated CBD. However, it is important to note that the procedure's success depends on various factors, including patient characteristics and surgeon expertise.

4. Conclusion

Laparoscopic CBD exploration using a cholangioscope through modified trans-choledochal tube helps to prevent the leakage of fluid and stone fragments into the abdomen and out of the surgical site, it helps the cholangioscope to work stably and increase the ability to remove stones. This effective and safe technique may be considered a standard approach to treating hepatolithiasis combined with dilated CBD.

Informed consent

That statement indicates that the patient whose case is being reported in the journal provided written consent before the case report and associated pictures were published. The purpose of obtaining informed consent is to ensure that patients are aware of the publication and any identifiable information that may be included. By obtaining written consent, the journal demonstrates its commitment to protecting the privacy and rights of the patient.

Additionally, the statement suggests that the Editor-in-Chief of the journal has the authority to verify the existence of the written consent. If requested, they can examine a copy of the written consent to confirm that the necessary permission was obtained from the patient.

Ethical approval

This study was approved by Institutional Ethical Committee, No: 168/QĐ-HGMT.

Funding

The study did not receive external funding.

Guarantor

LE Trung Hieu.

Research registration number

• 1.Name of the registry: Researchregistry.com
• 2.Unique identifying number or registration ID: researchregistry9046
• 1.Hyperlink to your specific registration (must be publicly accessible and will be checked): https://www.researchregistry.com/browse-the-registry#home/registrationdetails/64682853bb0c2800272ee1f8/.

CRediT authorship contribution statement

Concept, consent, literature review, drafting of the initial and final manuscript, approval of the final manuscript - All authors.

Declaration of competing interest

We have no conflicts of interest to disclose.