The design and performance of laparoscopic video biliary operations

 Hong Bing Xu, Yin Qi Xiao, Wei Min Li, Hu Cheng Li, Xiang Qun Tu

Subject headings Laparoscopy; drainage; anastomosis, Rouxa2ena2Y; choledochostomy

Xu HB, Xiao YQ, Li WM, Li HC, Tu XQ. The design and performance of laparosc opic video biliary operations. 
China Nati J New Gastroenterol, 1996;2(2):92-94

Abstract

AIM To explore and enlarge the application range of laparoscopic video technology in biliary surgery.

METHODS  Since November 1992, laparoscopic video choledocholithotomy T-tube drainage (LCTD) for 45 cases and laparoscopic video choledochojejunostomy (LCJS) for 5 cases have been designed and performed, its indications and the main technical procedures were discussed and presented here.

RESULTS  The procedures of LCTD for 45 cases were successful. One patient with sustained biliary leakage and one patient with sustained residual choledocholith were perfectly cured. The procedures of LCJS for 5 cases were also successful and all the patients soon recovered without any complications. 

CONCLUSION  The results show that LCTD and LCJS are characterized by minor trauma, less sufferings, fast postoperative recovery, good curative effect and hence are worth popularizing and applying.The designed and performed laparoscopic video biliary operations are not only in conformity with the biliary surgical therapeutic principle, but also easy to operate, economic, practical and convenient for performance.



INTRODUCTION
Since November 1992, the application range of laparoscopic video technology in biliary surgery has been further explored and enlarged on the basis of successful application of laparoscopic video cholecystectomy (LC) in our hospital so that laparoscopic video biliary operations, including laparoscopic video choledocholithotomy T-tube drainage (LCTD)^£Û1£Ý for 45 cases and laparoscopic video choledochojejunostomy (LCJS)^£Û2£Ý for 5 cases, have been successfully performed and satisfactory results have been achieved. Now, the indications and main technical procedures of LCTD and LCJS are presented as follows:ª¤

MATERIALS AND METHODS

Surgical instruments
The instruments for LCTD include 25¡ã wide-angle laparoscope with the necessary equipment made by the WOLF Company in Germany, Olympus P-20 choledochofiberscope with the necessary equipment made in Japan, and the selfª²made common additional biliary appliances. The instruments for LCJS include Endo GIA, Endo Gauge, Endo Babcock, Endo Retract and Endo clip made by ETHICON Company in USA, and LCTD instruments.ª¤ª¤

Anesthesia, posture and puncture
Under general anesthesia, the patient is placed in semisupination of 20¡ã, inclining to the left of 10¡ã-15¡ã, with a slight elevation of the right lumbar region. After the artificial pneumoperitoneum, the four trocars are inserted in the abdomen with the viewing incision localizing in the lower margin of umbilicus and the main operational incision 3?cm under the xiphoid and 3?cm to the right  of midline. The diameter of each of them is 1cm. The other two aditional incisions are separate, in the right inferocostal midclavicular line and the anterior axillary line, each of them being 0.5cm in diameter. The anesthesia, posture and the first four incisions of LCJS are the same as those of LCTD, but the diameter is 1cm. An inserted incision of Endo GIA is added in the intermediate part of the straight muscle of the right upper abdomen with a diameter of 1.2cm.ªªª¤ª¤

Methods
The cystic duct is first dissected and clipped with a titanium clip. Common bile duct (CBD) is exposed. The junction of cystic duct and commonhepatic duct (CHD) is confirmed by a puncture and is then incised 2cm in length with the sickle type surgical knife. The choledochofiberscope is inserted into CBD and the gallstones are removed with gallstone forceps and scoops £Ûif the number of gallstones are less than three (small and free), they can also be removed with the lithotomy net of the choledochofiberscope£Ý. No.3-6 biliary tract bougies are passed through Oddi¡äs muscle, a urinary catheter is inserted into CBD for douche, and the choledochofiberscope is inserted into CBD again to confirm the extraction of all gallstones. The two short arms of Tª²tube are put into CBD, the incision of CBD is closed with 1-3 stitches, and a tight knot is tied with a short thread or both the suture roots are clipped to suture the incision. The gallbladder is excised and removed through the umbilical incision and finally the long arm of T-tube is pulled out through the incision in the midclavicular line, and a drainage-tube placed in Winslow¡äs foramen is pulled out through the incision in the anterior axillary line. In case of biliogenic pancreatitis, the tube, as a drainage-tube or a perfusion-tube, is inserted into the omental bursa through Winslow¡äs foramen, the gastrocolic ligament is opened, the head of the other emulsion-tube is placed in the region of the tail of pancreatic body and the tail of the tube is pulled out through the other incision punctured in the left upper abdomen for the postoperative lavage of pancreas. According to the condition, decompression gastrostomy and nutritional jejunostomy can be performed under the videolaparoscope.ª¥
          The anterior layer of hepatoduodenal ligament is striped so that the duodenal posterior segment of CBD is fully exposed and its inferior extremity is incised 1cm to remove the stones. The opposite mesangial margin of jejunum which is 30cm from Treitz¡äs ligament is transected 1cm in length. An Endo GIA 30 is in serted upward through the two small incisions of CBD and jejunum for precolonic choledochojejunostomy (CJS) 3?cm, and the two short arms of T-tube are put into CHD through the small incision beneath the anastomotic stoma. The small incision is closed with continuous whole layer inversion suture and interrupted sero-muscular suture. Jejunal affrerent loop which is 20?cm from Treitz¡äs ligament is made by a 1cm small incision, and the efferent loop which is 50cm from CJS is also made by a 1cm small incision. An Endo GIA 30 is inserted downward through the two small incisions of the loops for jejunal afferent-efferent loop anastomosis 3cm, near the anastomotic stoma; the afferent loop is severed with an Endo GIA 30; at the same time, both severed ends are closed, and the small incision is closed in the aboveª²mentioned way. Like LCTD, the gallbladder is excised and removed, with T-tube and drainage-tube being pulled out. LCJS is shown in Figure 1.ª¤

Figure 1 LCJSª¤ª¤

RESULTS
The procedures of LCTD for 45 cases were successful. One patient with sustained biliary leakage and one patient with sustained residual choledocholith were both cured perfectly. The procedures of LCJS for 5 cases were also successful and all the patients recovered without any complications. Usually gastrointestinal functions restored 24 hours after LCTD or LCJS and the patients could then take food. The T-tube could be extracted two or three weeks after LCTD or LCJS if T-tube cholangiography did not show any abnormal results.ª¤ª¤

DISCUSSION

surgery indications
LCTD: LCTD is suitable for the patients ¢Ù- in cases of gallstones complicated with secondary choledocholith, especially the patients who are fat, aged, complicated with diabetes so that they usually connot tolerate a major surgical operation; ¢Ú- in cases of primary or secondary choledocholith complicated with acute cholangitis or biliogenic pancreatitis, the risk patients for an emergency who can not tolerate major operations. Simple choledocholithotomy with T-tube drainage for primary choledocholith  usually yields poor result, for biliary stones can be easily missed with high recurrence, these patients should be treated with LCJS. However, in cases of severe cholangitis or acute hemorrhagic necrotic pancreatitis, if patients present shock and diffuse peritonitis, they should be treated with routine surgical operations.ª¥
         LCJS: LCJS is suitable ¢Ù- in cases of primary choledocholith or hepatolith, without stricture of intrahepatic duct and with CBD having a diameter £¾1.5cm; ¢Ú- in cases of benign distal obstruction of CBD with coexistence of pancreatitis, cholangitis or duodentitis;¢Û- in cases of malignant obstruction and late stage cancer which need palliative treatment of jaundice. However, in cases of stricture of intrahepatic duct, high level malignant biliary obstruction, there is no indication for LCJS.ª¤ª¤ 

The main points for operations
LCTD: ¢Ù- The viewing incision is located in lower margin of umbilicus. If the patient has an operative history in the lower abdomen, the Trocars must be inserted into the abdomen through an incision so as to avoid injuring abdominal organs by a blind puncture. ¢Ú- Calot¡äs triangle is dissected from gallbladder neck, the anterior layer and posterior one of serous coat are opened to expose the junction of gallbladder neck and cystic duct, blunt dissection is performed towards CBD and the region of CBD must not be dissected. As soon as the part of the cystic duct is exposed, it must be clipped so as to prevent bile duct injury. ¢Û- Proximal end of cystic duct is clipped with two titanium clips, the dissection of the cystic artery is not ¡°skeletalª²changed¡± so that the chances of cystic duct stump leakage and bleeding are decreased.¢Ü- CBD can be seen clearly after the raise of the lumbar region. ¢Ý- The incision under xiphoid is at the right midline in order that LCTD could be performed easily. ¢Þ- The cystic duct is first dissected and clipped with a titanium clip, if the gallstones pass to CBD during the operation. Temporarily the cystic duct is not amputated and the gallbladder is not dissected either, thus the traction of the gallbladder could push the hepatic margin up at the same time, and the gallbladder bed could be prevented from being early denuded with bleeding blurring the operative field. ¢ß- The sickle-type surgical knife blade must be used to incise CBD which can not only make the incised margins regular, but also avoid injuring the posterior wall of CBD. ¢à- Lithotomy relies mainly on the common lithotomic apparatus while making the fiberscope subsidiary. When the two sutures of the incision could not be tied in a tightknot, both the suture roots should be clipped to suture the incision, the refore the operation is simple, economical and easy to be popularized. ¢á- A thicker cystic duct is amputated by repeated clipping and cutting. ¢â- If the stones in CBD are numerous and lithotomy time is longer, the lithotomy can be stopped and a T-tube is put in. Three weeks after LCTD, lithotomy can be performed again with the fibersope passing through the T-tube sinus. B11ª£- In cases of biliogenic pancreatitis, decompression gastrostomy and nutritional jejunostomy can be performed under the videolaparoscope.
     LCJS: ¢Ù- Endo GIA is inserted through the intermediate part of the straight muscle of the right upper abdomen so that LCJS could be performed easily.¢Ú- Temporarily, the gallbladder is not first excised, thus the traction of the gallbladder could make CBD exposed clearly. ¢Û- CBD is dissected until its duodenal posterior segment, and inferior extremity of CBD are incised to remove the stones. ¢Ü- Precolonic ansiform CJS is much easier and simpler than postcolonic Roux-en-Y CJS. ¢Ý- The anastomotic stoma of CJS is 30?cm apart from Treitz¡äs ligament, a T-tube is inserted into CBD through the small incision beneath the anastomotic stoma.¢Þ- Jejunal afferentª²efferent loop anastomosis is performed. Above the anastomotic stoma, the afferent loop is 10cm and the efferent loop,50cm, then the afferent loop is severed, therefore, ansiform CJS is nearly changed into Roux-en-Y CJS, and ascending infection could be avoided.¢ß- Near the afferentª²efferent loop anastomotic stoma, the afferent loop is severed so that a cecum can not be survived to avoid a secondary infection.ª¥
         Laparoscopic video biliary operations which we have developed and performed are not only in conformity with the biliary surgical therapeutic principle, but also easy to operate, inexpensive, practical and convenient for performance. Our results show that LCTD and LCJS are characterized by making patients have little trauma, less sufferings, quick postoperative recovery, good curative effect. Therefore we suggest that LCTD and LCJS be popularied and applied in medical practice.ª¤ª¤

REFERENCES
1  Xu HB, Li HC, Xiao YQ, Zhou YP, Li WM. Clinical studies on LCTD. Endosc Sur, 1994;1(1)suppl:245-246
2  Xu HB, Xiao YQ, Li HC, Peng XX, Li WM. The design and operation of laparoscopic video choledochojejunostomy.J Endosc Sur,
    1994;1(1)suppl:286-287

Xu Hongª²Bing, Associate Professor of Surgery, having 60 papers and four books published. Viceª²Director of the Department of Hepatobiliary Surgery, Chinese PLA 309 Hospital, Beijing 100091, China.ª¤Presented at ¡ä95 Shanghai International Laparoscopic Surgery Symposium.Shanghai China, 1995.ª¤
Correspondence to Dr. Xu Hong Bing,Director of the Department of Hepatobiliary Surgery, Chinese PLA 309 Hospital, Beijing 100091, China.
Tel. +86¡¤10¡¤66767729-993.
Received  27 November 1995,  revised -5 May 1996.