Laparoscopic Transcystic Laser Lithotripsy for Common Bile Duct Stone Clearance

First experiences with a diode laser in major gynecological laparoscopic procedures show lack of benefit and impaired feasibility

PURPOSE

The aim of this study is to evaluate feasibility and potential benefit of a diode laser in major laparoscopic procedures in gynecology.

METHODS

Between 2018 and 2020, a total of 42 cases were enrolled in this study comparing standard electrosurgery with diode laser-supported therapy in laparoscopic supracervical hysterectomy (LASH), total laparoscopic hysterectomy (TLH), or laparoscopic myoma enucleation (LME). Dual wavelength 45 W diode laser light was used to cut and coagulate during laparoscopy in the prospective interventional arm consisting of 11 cases, while 31 matching patients who received conventional treatment with monopolar/bipolar current for the same interventions were retrospectively identified in our laparoscopy database. Recruitment in the prospective interventional laser diode arm was terminated after only 11 patients (instead of planned 50) due to intense hemorrhage and massive smoke development.

RESULTS

A total of 42 cases were analyzed (11 LME, 19 LASH, and 12 TLH). Strong smoke development was evident in all 11 cases in the diode laser arm. It was necessary to convert to bipolar or monopolar current in all hysterectomies (n = 9) with initial diode laser implementation due to increased bleeding and smoke development. Conventional current sources had to be used in LMEs (n = 2) due to excessive bleeding and poor visibility during enucleation of the fibroid. A significant difference (p < 0.0001) was observed regarding smoke development when comparing the laser arm with the control arm.

CONCLUSION

We found a 45-W diode laser to be inferior to electrosurgical techniques for major laparoscopic gynecologic surgeries regarding bleeding control and smoke development.

Laparoscopic management of type II Mirizzi syndrome

BACKGROUND

Mirizzi syndrome is an uncommon complication of longstanding gallstone disease. Pre-operative diagnosis is challenging, and to date, there is no consensus on the standard management for this condition. Until recently open cholecystectomy was the standard of care for type II Mirizzi syndrome (McSherry classification). The objective of this study was to assess the incidence and management of type II Mirizzi syndrome in patients with proven or suspected choledocholithiasis undergoing laparoscopic common bile duct (CBD) exploration and present our experience in the laparoscopic management of this rare condition over the last 21 years.

METHODS

Prospective data collection of eleven cases of type II Mirizzi syndrome amongst a series of 425 laparoscopic bile duct explorations was performed between 1998 and 2019. Demographic, clinical, diagnostic, intra-operative, and post-operative data were recorded.

RESULTS

The incidence of type II Mirizzi syndrome was 2.6% in 425 laparoscopic CBD explorations. All operations were completed laparoscopically with closure of the defect over a decompressed CBD (T-tube n = 3, antegrade stent n = 5, transcystic drain n = 2), and in one case a non-drained duct was closed with Endoloop. Stone clearance rate was 100% (11 cases). In two patients the transinfundibular approach was used in conjunction with holmium laser lithotripsy to enable choledochoscopy and successful stone clearance. Three patients were complicated in the post-operative period with bile leak (n = 2) and lower respiratory tract infection (n = 1). An incidental gallbladder carcinoma was found in one patient.

CONCLUSION

Laparoscopic management of type II Mirizzi syndrome is feasible and safe when performed by experienced laparoscopic foregut surgeons. Laparoscopy and choledochoscopy can be combined with novel approaches and techniques to increase the likelihood of treatment success.

Holmium laser lithotripsy improves the rate of successful transcystic laparoscopic common bile duct exploration

Purpose

Transcystic laparoscopic common bile duct exploration (LCBDE) seems safer than transductal LCBDE and is associated with fewer biliary complications. It has traditionally been limited to smaller bile duct stones however. This study aimed to assess the ability of laser-assisted bile duct exploration by laparoendoscopy (LABEL) to increase the rate of successful transcystic LCBDE in patients with bile duct stones at the time of laparoscopic cholecystectomy.

Methods

Patients undergoing LCBDE between 2014 and 2018 were retrospectively analysed. Baseline demographic and medical characteristics were recorded, as well as intra-operative findings and post-procedure outcomes. Standard LCBDE via the transcystic route was initially attempted in all patients, and LABEL was only utilised if there was failure to achieve transcystic duct clearance. The transductal route was utilised for failed transcystic extraction.

Results

One hundred and seventy-nine consecutive patients underwent LCBDE; 119 (66.5%) underwent unaided transcystic extraction, 29 (16.2%) required LABEL to achieve transcystic extraction and 31 (17.3%) failed transcystic extraction (despite the use of LABEL in 7 of these cases) and hence required conversion to transductal LCBDE. As such, LABEL could be considered to increase the rate of successful transcystic extraction from 66.5% (119/179) to 82.7% (148/179). Patients requiring LABEL were however more likely to experience major complications (CD III–IV 5.6% vs 0.7%, p = 0.042) although none were specifically attributable to the laser intra-operatively.

Conclusions

LABEL is an effective adjunct to LCBDE that improves the rate of successful transcystic extraction.

Technical Aspects of Bile Duct Evaluation and Exploration: An Update

Consensus guidelines recommend patients with symptomatic cholelithiasis and suspected choledocholithiasis have common bile duct exploration (CBDE) at the time of cholecystectomy to prevent downstream problems. Despite superiority of single-stage cholecystectomy with CBDE, 2-stage precholecystectomy/postcholecystectomy with endoscopic clearance of the duct is commonly practiced. This is related to inadequate training in minimally invasive techniques, lack of technical support for efficient and safe CBDE, and surgeons' inexperience with complex biliary pathologic condition. This article provides a framework for evaluating and treating patients with CBD pathologic condition with an emphasis on technical aspects of CBDE and preoperative planning and preparation.

Efficacy and safety of laparoscopic holmium laser lithotripsy in the treatment of complicated biliary calculus: A PRISMA-compliant systematic reviews and meta-analysis

BACKGROUD

The aim of this study was to assess the efficacy and safety of laparoscopic holmium laser lithotripsy (LHLL) in the treatment of complicated biliary calculus.

METHODS

We systematically searched the electronic database (PubMed, EMBASE, Cochrane library, Web of science, and Chinese Biomedical Literature Database) up to May 2018 to identify case-controlled studies that compared LHLL with laparoscopic bile duct exploration (LBDE) for complicated biliary calculus.

RESULTS

Five case-controlled studies were included, with 541 patients (273 in the LHLL group and 268 in the LBDE group). Compared with LBDE, LHLL was associated with shorter operative time (weighted mean difference [WMD] = -40.04, P < .001) and lower estimated blood loss (EBL) (WMD = -56.42, P < .001), lesser duration of hospitalization (WMD = -3.93, P < .001) and lower rate of residual stone (OR = 0.13, P < .001). There was no statistically significant differences in bile leakage (OR = 0.48, P = .23) and hemobilia (OR = 0.49, 0.41).

CONCLUSION

Current evidence suggests that the efficacy of LHLL is superior to that of LBDE but they are similarly safe for the treatment of complicated biliary calculus. Limited by the quantity and quality of the studies included, these conclusions need to be verified by more high-quality studies.

Biliary and pancreatic lithotripsy devices

BACKGROUND AND AIMS

Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL).

METHODS

In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations.

RESULTS

Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs.

CONCLUSIONS

Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.

Key techniques and procedure optimization of laparoscopic hepatectomy for hepatolithiasis

Hepatolithiasis is a common and refractory benign biliary tract disease in China. Meta-analyses show that laparoscopic hepatectomy (LH) is safe and effective for this disease. LH for hepatolithiasis has its distinctive techniques and procedures due to its unique clinicopathological characteristic in the era of precise hepatecomy and enhanced recovery after surgery. The key techniques include individualized selection of operating hole, hepatic inflow occlusion, anatomical hepatectomy, fine dissection, and other combined techniques. As for procedures, hepatecomy should be completed before extrahepatic bile duct choledocholithotomy is performed, and the portal hepatis should be preferentially dissected before the perihepatic ligaments are separated.

A novel laparoscopic transcystic approach using an ultrathin choledochoscope and holmium laser lithotripsy in the management of cholecystocholedocholithiasis: An appraisal of their safety and efficacy

BACKGROUND

Although laparoscopic transcystic common bile duct exploration (LTCBDE) is the preferred approach for CBD stone clearance, the success rate can vary between 55% and 85%. This study evaluated if ultrathin choledochoscope and holmium laser lithotripsy could improve the success rate of LTCBDE.

METHODS

Records of 126 patients (average age, 46.1 ± 13.8 years) with cholecystocholedocholithiasis treated with laparoscopic cholecystectomy (LC) and LTCBDE were retrospectively reviewed.

RESULTS

LC+LTCBDE was performed successfully in 118 of 126 patients, with a surgical success rate of 93.7%. An ultrathin choledochoscope was used in 75 (63.5%) patients, and holmium lithotripsy was performed in 38 (32.2%) patients. The stone clearance rate was 99.2% (117/118). No significant complications occurred. One hundred (84.7%) patients had excellent and 13 (11%) had good outcomes for an overall success rate (excellent plus good) of 95.7%.

CONCLUSION

Ultrathin choledochoscope and holmium laser lithotripsy can improve the surgical outcomes of LC+LTCBDE with minimal complications.

LABEL procedure: Laser-Assisted Bile duct Exploration by Laparoendoscopy for choledocholithiasis: improving surgical outcomes and reducing technical failure

BACKGROUND

Laparoscopic bile duct exploration (LBDE) is recommended in current treatment guidelines for the management of choledocholithiasis with gallbladder in situ. Failure of this technique is common as a consequence of large or impacted common bile duct (CBD) stones. In this series, we present our experience in using holmium laser lithotripsy as an adjunct to LBDE for the treatment of choledocholithiasis.

METHODS

Between 2014 and 2016, eighteen laparoscopic bile duct explorations utilising holmium laser lithotripsy were performed after failure of standard retrieval techniques.

RESULTS

Choledocholithiasis was successfully treated in 18 patients using laparoscopic holmium laser lithotripsy (transcystically in 14 patients). There was one failure where a CBD stricture prevented the scope reaching the stone. Two medical complications were recorded (Clavien-Dindo I and II). There were no mortalities or re-interventions.

CONCLUSIONS

LABEL technique is a successful and safe method to enhance LBDE in cases of impacted or large stones. In our experience, this approach increases the feasibility of the transcystic stone retrieval and may reduce overall operative time.

Management of impacted common bile duct stones during a laparoscopic procedure: A Retrospective Cohort Study of 377 Consecutive Patients

INTRODUCTION

To explore the techniques for managing impacted common bile duct (CBD) stones during laparoscopic common bile duct exploration (LCBDE).

METHODS

We retrospectively analyzed 377 consecutive patients undergoing LCBDE from January 2008 to June 2015. Group 1 was defined as patients with impacted CBD stones. Group 2 included patients without impacted CBD stones. The outcomes of LCBDE were compared between the two groups.

RESULTS

There were 65 patients in Group 1 and 312 patients in Group 2. The incidence of jaundice, abnormal liver function tests, cholangitis and pancreatitis was higher in Group 1. Forty-one patients with small impacted CBD stones were managed using the tipless Nitinol basket. Seventeen patients with large impacted CBD stones and 7 patients with small impacted CBD stones underwent laser lithotripsy via choledochoscopy. None of the patients in Group 1 was converted to open procedures for impacted CBD stones. Operation duration was 13.6 min longer in Group 1 (133.2 min). Postoperative hospital stay was significantly longer in Group 1 (9.7 ± 2.5 d) than in Group 2 (6.3 ± 1.8 d). There was no difference in the overall postoperative complication rate, retained stone rate, and recurrence rate between the two groups.

CONCLUSION

Rational utilization of laser lithotripsy and an appropriate basket in LCBDE may avoid conversion to open procedures in patients with impacted CBD stones.

Effects of intravenously infused lidocaine on analgesia and gastrointestinal function of patients receiving laparoscopic common bile duct exploration

Objective:

To evaluate the effects of intravenously infused lidocaine on analgesia and gastrointestinal function of patients receiving laparoscopic common bile duct exploration.

Methods:

Seventy-eight patients with cholelithiasis were randomly divided into a treatment group and a control group (n=39) that all had laparoscopic common bile duct exploration. The treatment group was intravenously infused with 1.5 mg/kg lidocaine by using a venous pump under anesthesia induction at the speed of 2 mg·kg^-1 ·h^-1 until the end of surgery, while the control group was given normal saline with the same volume.

Results:

All patients successfully completed the surgery, with similar surgical time, incision length and intraoperative blood loss. The required lidocaine concentrations of the treatment group were 2.64±1.23 μg/ml, 1.14±0.4 μg/ml and 0.93±0.32 μg/ml respectively 2 hour, 12 hour and 48 hour after surgery. Pain score of the treatment group, which was significantly lower than that of the control group at the postoperative 2 hour (P<0.05), was similar to those of the control group at the postoperative 12 hour and 48 hour. With extended time, the pain score significantly decreased (P<0.05). The treatment group had significantly shorter first anal exhaust time and first defecation time than those of the control group (P<0.05). Adverse reactions, such as nausea and vomiting, dizziness, headache, subcutaneous emphysema and fat liquefaction of incision, occurred similarly in the two groups, which were alleviated by symptomatic treatment.

Conclusion:

Laparoscopic common bile duct exploration is a promising minimally invasive surgery for patients with cholelithiasis, during which intravenously infused lidocaine can rapidly recover the gastrointestinal function and exert short-term analgesic effects, with mild adverse reactions also.