Application of "three lines and one plane" as anatomic landmarks in laparoscopic surgery for bile duct stones

Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence

While endoscopic retrograde cholangiopancreatography (ERCP) remains the primary treatment modality for common bile duct stones (CBDS) or choledocholithiasis due to advancements in instruments, surgical intervention, known as common bile duct exploration (CBDE), is still necessary in cases of difficult CBDS, failed endoscopic treatment, or altered anatomy. Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes. This review elucidates relevant clinical anatomy, selection indications, and outcomes to enhance surgical understanding. The selection between trans-cystic (TC) vs trans-choledochal (TD) approaches is described, along with stone removal techniques and ductal closure. Detailed surgical techniques and strategies for both the TC and TD approaches, including instrument selection, is also provided. Additionally, this review comprehensively addresses operation-specific complications such as bile leakage, stricture, and entrapment, and focuses on preventive measures and treatment strategies. This review aims to optimize the management of CBDS through laparoscopic CBDE, with the goal of improving patient outcomes and minimizing risks.

The hilar plane compared with the Rouviere's sulcus plane during laparoscopic cholecystectomy

Introduction

Rouviere's sulcus (RS) has been widely used as an important landmark during laparoscopic cholecystectomy; however, some shortcomings remain unaddressed.

Aim

To evaluate the safety and application values of the hilar plane in laparoscopic cholecystectomy (LC) by comparing it with the plane of Rouviere's sulcus (RS plane).

Material and methods

A retrospective study of 155 consecutive patients undergoing LC used the hilar plane as a guide for surgical procedures was performed. Intraoperative images were used to evaluate and analyze the value of using the hilar plane vs. the RS plane in preventing bile duct and vascular injuries. Meanwhile, anatomical data, including the types and orientations of Rouviere's sulci, were also recorded for further analysis.

Results

Rouviere's sulci failed to be identified clearly in 9 cases due to severe adhesions. The prevalence of RS was 83.6% (122/146). The hilar plane was a constant landmark. The hilar plane can also form a "security dissection triangle" in the posterior triangle of the gallbladder. The hilar plane and the RS plane formed a similar triangle in 59.8% (73/122) of cases, while in other cases, the hilar plane formed a smaller dissection triangle than the RS plane due to a higher spatial position. The hilar plane had a better protective effect for avoiding ectopic hepatic ducts or ectopic right hepatic arteries injury.

Conclusions

The hilar plane has the features of constant location, large coverage area, and higher location, hence being further away from the critical structures. The hilar plane on its own can provide a safe anatomic plane in some case when RS was difficult to observe or identify.

The supraduodenal pedicle can be a useful landmark of the common bile duct in laparoscopic cholecystectomy

This investigation was undertaken to determine whether the supraduodenal pedicle (SP) can assist in defining the location of the common bile duct (CBD) during laparoscopic cholecystectomy (LC). The supraduodenal pedicle was recognizable in 100/122 (82%) consecutive patients undergoing LC in this hospital. The SP displayed either thin (9/100, 9%) or obvious thick vessels (91/100, 91%), 38/100 (38%) cases showed a single branch vessel and 62/100 (62%) cases showed two or more branches. The CBD and SP were both present in 68/100 (68%) patients. The right most branch of the SP ran along the ventral (40/68, 58.8%) or the left edge (28/68, 41.2%) of the CBD. In 32 cases with an invisible CBD but a visible SP, the CBD was successfully found close to the right most branch of the SP in all patients after slightly separating them. The SP can be a useful landmark to quickly and accurately locate the CBD in LC.