Robotic gastrectomy is more beneficial for advanced than early-stage gastric cancer: a comparison with laparoscopic gastrectomy using propensity score matching.

BACKGROUND: Gastric cancer is the fifth most prevalent malignancy globally and the fourth major contributor to cancer-related mortality. The comparative effectiveness of robotic gastrectomy (RG) versus laparoscopic gastrectomy (LG) at different stages of gastric cancer is unclear regarding surgical and survival outcomes. We compared surgical and survival outcomes between RG and LG in early-stage (cStage I) and advanced (cStage II/III) gastric cancers to elucidate the difference in the efficacy of RG across various stages of gastric cancer. METHODS: We identified 299 patients (LG, 170; RG, 129) with cStage II/III disease and 569 (LG, 455; RG, 114) with cStage I disease who underwent either LG or RG. Following propensity score matching for RG and LG, 118 pairs were selected for cStage II/II and 113 pairs for cStage I. Surgical and survival outcomes of LG and RG were separately compared for cStage II/III and cStage I. RESULTS: In cStage II/III, RG showed significantly fewer intra-abdominal complications of Clavien-Dindo (C.D.) Grade ≥ III in the RG group than in the LG group (LG = 8.5 vs. RG = 1.7%, P = 0.033). Multivariate analysis identified LG as an independent risk factor for intra-abdominal complications of C.D. Grade ≥ III (OR 5.69, 95% CI 1.17-27.70, P = 0.031). However, in cStage I, no difference in surgical outcomes between LG and RG was observed. No differences were observed in survival outcomes between LG and RG in both cStage I or cStage II/III. CONCLUSIONS: The real benefit of RG was demonstrated in surgical outcomes, especially for advanced-stage gastric cancer.

Macroscopic type is implicated in the prognostic impact of initial chemotherapy on peritoneal lavage cytology-positive gastric cancer with no other noncurative factors.

BACKGROUND: Initial chemotherapy (Initial-C) followed by surgery is a promising treatment strategy for peritoneal lavage cytology-positive gastric cancer (CY1 GC) with no other noncurative factors. The aim of this study was to investigate the survival advantage of Initial-C compared to initial surgery (Initial-S) for this disease according to the macroscopic type, which was associated with prognosis and the efficacy of chemotherapy in GC. METHODS: One hundred eighty-nine patients who were diagnosed with CY1 GC with no other noncurative factors at four institutions from January 2007 to December 2018 were enrolled. The patients were divided into a macroscopic type 4 group (N = 48) and a non-type 4 group (N = 141). The influence of initial treatment on overall survival (OS) in each group was evaluated. RESULTS: In the type 4 group, the 5-year OS rates of Initial-C (N = 35) and Initial-S (N = 13) were 11.6% and 0%, respectively (P = 0.801). The multivariate analysis could not show the survival advantage of Initial-C. In the non-type 4 group, the 5-year OS rates of Initial-C (N = 41) and Initial-S (N = 100) were 48.4% and 29.0%, respectively (P = 0.020). The multivariate analysis revealed that Initial-C was independently associated with prolonged OS (hazard ratio, 0.591; 95% confidence interval, 0.375-0.933: P = 0.023). CONCLUSIONS: Initial-C improves the prognosis of non-type 4 CY1 GC with no other noncurative factors. On the other hand, further development of effective chemotherapeutic regimens and innovative treatment strategies are required for type 4 CY1 GC.

Comparison of Surgical and Oncological Outcomes of Laparoscopic and Open Gastrectomy for Pathologically Serosa-Invasive (pT4a) Advanced Gastric Cancer-Retrospective Propensity Score-Matched Analysis.

Background: We aimed to clarify the operative feasibility and oncological efficacy of a laparoscopic gastrectomy (LG) for pT4a gastric cancer through comparison with open gastrectomy (OG). Materials and Methods: We compared surgical and oncological outcomes in 178 patients with pT4a gastric cancer who underwent LG or OG between 2002 and 2016; the background was adjusted using propensity score matching. Results: After score matching, 45 patients were included in each group. The LG group had a significantly longer operation time (277 minutes versus 175 minutes, P < .001) and lower estimated blood loss (50 mL versus 280 mL, P < .001). The total number of dissected lymph nodes did not differ between groups (46 versus 38, P = .119); however, the number of dissected suprapancreatic lymph nodes was significantly higher in the LG group (11 versus 7.5, P = .011). Postoperative morbidity rates did not differ between groups. Postoperative hospitalization was significantly shorter in the LG group (7 days versus 13 days, P < .01), whereas overall survival, disease-free survival, and cancer recurrence rates and patterns were similar between groups. Conclusions: LG for pT4a gastric cancer has feasible and acceptable outcomes compared with OG.

Outcomes of elderly patients following thoracoscopic esophagectomy for esophageal cancer.

PURPOSE: Thoracoscopic esophagectomy (TE) is widely used for esophageal cancer treatment. However, the short- and long-term outcomes of TE in older patients remain unknown. Thus, we investigated those outcomes as well as the effectivity of TE in this patient cohort. METHODS: A total of 228 consecutive patients who underwent TE for esophageal cancer from 2002 to 2015 were included in the study and categorized into the elderly (≥ 75 years) and non-elderly (< 75 years) groups. The background was adjusted by propensity score matching. The short- and long-term outcomes were then compared between the two groups. RESULTS: There was no difference in the short-term outcomes between the two groups. The elderly group had significantly lower overall survival (OS) and relapse-free survival (RFS) than the non-elderly group. When pulmonary complications occurred, the OS and RFS were significantly decreased in the elderly group but not in the non-elderly group. Without pulmonary complications, the OS and RFS in the elderly group did not differ from those in the non-elderly group. The multivariate analysis showed that pulmonary complications were independent poor prognostic factors for OS and RFS in the elderly group but not in the non-elderly group. CONCLUSION: TE is safe and feasible for older patients. However, the OS and RFS of the elderly group were significantly worse than those of the non-elderly group, especially when pulmonary complications occurred. Therefore, perioperative management to prevent pulmonary complications is essential to improve the long-term outcomes of older patients receiving TE.

Conversion surgery for stage IV gastric cancer: a multicenter retrospective study.

BACKGROUND: Recent improvements in systemic chemotherapy have provided an opportunity for patients with stage IV gastric cancer (GC) to undergo conversion surgery (CS). The aim of this study was to evaluate the long-term outcomes of patients who underwent CS and to elucidate the prognostic factors for CS in stage IV GC. METHODS: A total of 79 patients who underwent CS with the aim of R0 resection for stage IV GC at six institutions from January 2008 to July 2019 were enrolled. We retrospectively reviewed the clinicopathological data and prognosis. RESULTS: Of the 79 patients, 23 (31.1%) had initially resectable disease (IR) before chemotherapy, defined as positive for cancer on peritoneal cytology (CY1), resectable hepatic metastasis, or para-aortic lymph node No. 16a2/b1 metastasis. Of the 56 remaining patients with primary unresectable disease, 39 had peritoneal dissemination. R0 resection was accomplished in 63 patients (79.7%). The 3-year OS rates for patients with IR and unresectable disease were 78.3% and 44.5%, respectively. Multivariate analysis showed that IR (P = 0.014) and R0 (P = 0.014) were statistically significant independent prognostic factors for favorable OS. Among patients with peritoneal dissemination alone, OS was significantly better for patients with R0 resection than for patients with R1/2 resection, with the 3-year OS rates of 65.5% and 23.1%, respectively (P = 0.011). CONCLUSIONS: CS is a treatment option for selected patients with stage IV GC. Patients with IR and patients who achieve R0 resection may obtain a survival benefit from CS.

Laparoscopic surgery for a hydrocele of the canal of Nuck with an ovarian tumor: An extremely rare clinical finding.

This clinical image presents an unusual report of simultaneous laparoscopic resection of a hydrocele of the canal of Nuck and an ovarian tumor. Laparoscopic treatment with a proper approach is a useful technique in some cases.

Laparoscopic transabdominal preperitoneal hernioplasty for bilateral obturator hernias and left inguinal hernia with emaciation caused by anorexia nervosa: A case report.

A 55-year-old woman receiving treatment for anorexia nervosa presented with abdominal pain and right thigh pain. Her body mass index was 12.9 kg/m2 . Computed tomography showed fluid storage in the distal side of the right obturator foramen and revealed a dilated small bowel without a starting point of obstruction. We diagnosed a naturally reduced incarcerated right obturator hernia and performed elective surgery with a laparoscopic approach for hernia repair the next day. Intraperitoneal observation revealed bilateral obturator hernias and a left direct-type inguinal hernia. Transabdominal preperitoneal hernioplasty was performed using two self-gripping polyester meshes for bilateral obturator hernia repair and a lightweight 3D-shaped mesh for left inguinal hernia repair. Women with emaciation caused by anorexia nervosa may be more likely to have complex hernias, including obturator hernia, and laparoscopic approaches may be useful for preoperatively diagnosed nonstrangulated obturator hernias.

Comparison of surgical smoke between open surgery and laparoscopic surgery for colorectal disease in the COVID-19 era.

BACKGROUND: Surgical smoke during operation is a well-known health hazard for medical staff. This study aimed to investigate the dynamics of surgical smoke during open surgery or laparoscopic surgery for colorectal disease. METHODS: This study quantitated particulate matter (PM) counts as part of surgical smoke in 31 consecutive patients who underwent colectomy at the Niigata City General Hospital using a laser particle counter. Particles were graded by size as ≤ 2.5 µm PM (PM2.5) or > 2.5 µm PM (large PM). Operative procedures were categorized as either open surgery (n = 14) or laparoscopic surgery (n = 17). RESULTS: The median patient age was 72 (range 41-89) years and 58.1% were male. The total PM2.5, PM2.5 per hour, and maximum PM2.5 per minute counts during operation were significantly higher in open surgery than in laparoscopic surgery (P = 0.001, P < 0.001, and P = 0.029, respectively). Large PM counts (total, per hour, and maximum per minute) were also higher in the open surgery group than in the laparoscopic surgery group. The maximum PM2.5 concentration recorded was 38.6 µm/m3, which is considered "unhealthy for sensitive groups" according to the U.S. Environment Protection Agency air quality index standards, if it was a 24-h period mean value. CONCLUSION: Exposure to surgical smoke is lower during laparoscopic surgery than during open surgery for colorectal diseases.

[A Case of Suspected Lynch Syndrome Due to Radical Resection for Descending Colon Cancer and Renal Pelvic Cancer].

A 60-year-old woman was admitted on account of presenting with bloody stools. She had a history of endometrial cancer surgery. Family history revealed 3 colorectal cancer cases among the first or second relatives. Colonoscopy and contrast- enhanced computed tomography revealed descending colon cancer and left renal pelvic cancer. We performed partial resection of the descending/transverse colon with D3 lymph node dissection and total resection of the left kidney and ureter with curative intent. Postoperative pathological diagnosis revealed descending colon cancer(pT4bN0M1c, pStage Ⅳc)and left renal pelvic cancer (T1N0M0, Stage Ⅰ). In this case, Lynch syndrome was suspected based on the family history and medical history. The clinical findings were consistent with Amsterdam Criteria Ⅱ. The microsatellite instability(MSI)test result was MSI-H and the BRAF genetic test result showed a wild type. Immunohistochemical staining of descending colon cancer tissue showed loss of expression of MSH2 and MSH6 proteins. Genetic counseling was provided because Lynch syndrome was strongly suspected. Capecitabine plus oxaliplatin therapy was performed for 6 months for descending colon cancer. Nine months postoperatively, the patient remained recurrence-free for both colon cancer and renal pelvic cancer. We report a case of suspected Lynch syndrome triggered by double cancer of the descending colon and renal pelvis.

Is radiological psoas muscle area measurement a predictor of postoperative complications after rectal resection for rectal cancer? A retrospective study.

PURPOSE: Previous studies have reported that sarcopenia increases the risk of postoperative complications following colorectal resection. This retrospective study assessed the postoperative complications of rectal resection associated with sarcopenia. METHODS: We retrospectively analyzed 262 patients who underwent curative low anterior resection for primary rectal cancer from January 2008 to May 2020 at our institution. The patients were divided into a sarcopenia group (normalized total psoas muscle area < 6.36 cm2/m2 in males and < 3.92 cm2/m2 in females; N = 49) and a non-sarcopenia group (N = 213). RESULTS: The overall rate of postoperative complications within 30 days of surgery was higher in the sarcopenia group than in the non-sarcopenia group (46.9 vs. 29.6%; P = 0.028). The rate of postoperative remote infections was higher in the sarcopenia group than in the non-sarcopenia group (12.2 vs. 2.8%; P = 0.012). Sarcopenia was found to be a predictor of remote infection by a multivariate analysis (odds ratio, 4.08; 95% confidence interval, 1.12-14.80; P = 0.033). CONCLUSION: Sarcopenia diagnosed using the psoas muscle index was found to be an independent predictive factor for postoperative remote infection after curative low anterior resection for rectal cancer.

A rare case of nivolumab-related myasthenia gravis and myocarditis in a patient with metastatic gastric cancer.

BACKGROUND: Although rare, several immune-related adverse effects can be life-threatening. Here, we describe a metastatic gastric cancer patient presenting with nivolumab-related myasthenia gravis and myocarditis, a previously unreported adverse effect of gastric cancer treatment. CASE PRESENTATION: A 66-year-old man with metastatic gastric cancer visited the emergency department because of dizziness after the first dose of nivolumab. Diagnoses of nivolumab-related myasthenia gravis and myocarditis were established. Myocardial biopsy results and anti-acetylcholine receptor antibody positivity confirmed the diagnoses. Despite plasma exchange and intravenous methylprednisolone and immunoglobulin administration, the patient's general condition gradually worsened, and he died. CONCLUSIONS: Strict monitoring for cardiac and neuromuscular symptoms after nivolumab administration is necessary to rapidly treat these adverse effects.

Ileo-right colonic reconstruction preserving all four colonic vessels after esophagectomy for cancer.

When colonic graft is used as an esophageal substitute after esophagectomy, one or two feeding vessels of the colon are cut to obtain sufficient length, the graft is passed via the subcutaneous route, and microvascular anastomosis is often used to avoid fatal complications. Sixteen consecutive ileo-right colonic reconstructions via the posterior mediastinal or retrosternal route with preservation of all four colonic vessels were performed in the past eight years. We presented the surgical technique and evaluation of this surgical method. In 15 out of 16 consecutive cases, the graft could be pulled up to the neck through the posterior mediastinal or retrosternal route while preserving all four colonic vessels. Reconstruction was not possible in one patient because of ileocolic vessel injury during colonic mobilization. Anastomotic leakage occurred in three patients, but all were minor and were treated conservatively. There were no patients with graft necrosis resulting from insufficient blood supply. Ileo-right colonic reconstruction with preservation of all four colonic vessels through the posterior mediastinal or retrosternal route is a safe and feasible procedure and is considered the first choice for colonic reconstruction as an esophageal substitute.

Surgical approach for right-sided colonic diverticular bleeding: A single-center review of 43 consecutive cases.

INTRODUCTION: While Asian populations develop colonic diverticular disease predominantly in the right colon, Western populations mainly present with left-sided disease. The present study aimed to clarify the outcomes of surgical treatment for right-sided colonic diverticular bleeding. METHODS: Medical records of 43 patients who underwent surgery for right-sided colonic diverticular bleeding between 2010 and 2019 were reviewed. Those whose general condition became unstable underwent open surgery at our institution. Patients were then divided into two groups, the open surgery group (n = 17) and laparoscopic surgery group (n = 26), after which operative outcomes between both groups were compared. RESULTS: This study included 36 men and seven women with a median age of 76 (range: 37-91) years. Laparoscopic surgery had a significantly longer operative time (183.5 minutes vs 110 minutes; P < .001) and significantly lower intraoperative blood transfusion rate (19.2% vs 82.4%; P < .001) than open surgery. The laparoscopic surgery group had earlier resumption of postoperative meals than open surgery group (postoperative day 3 vs postoperative day 4; P = .010). No significant difference in postoperative complications was observed between both groups. With regard to long-term outcomes, none of the cases exhibited rebleeding from the right-sided colon. CONCLUSION: The present study revealed that laparoscopic surgery promoted lower intraoperative blood transfusion rates and earlier resumption of postoperative meals compared to open surgery for right-sided colonic diverticular bleeding. Hence, laparoscopic surgery can be feasible for right-sided colonic diverticular bleeding provided that the patient's general condition is stable.

Influence of Suture Materials on Incisional Hernia Rate after Laparoscopic Colorectal Cancer Surgery: A Propensity Score Analysis.

OBJECTIVES: Incisional hernia is a common problem after colorectal surgery, and a laparoscopic approach does not reduce the incisional hernia rate. Previous reports have described the risk factors for incisional hernia; however, the impact of suture materials remains unclear. As such, this study compared the incisional hernia rate using different suture materials for abdominal wall closure after laparoscopic colorectal cancer surgery. METHODS: Patients undergoing laparoscopic colorectal cancer surgery between January 2014 and December 2016 were included in this study. We separated patients into the following two groups based on the suture materials used for abdominal wall closure: (1.) fast-absorbable group and (2.) non-absorbable group. The primary outcome was incisional hernia rate that was diagnosed using computed tomography. We compared outcomes between these two groups using propensity score matching. RESULTS: Before matching, 394 patients were included (168 in the fast-absorbable group and 226 in the non-absorbable group). After one-to-one matching, patients were stratified into the fast-absorbable group (n = 158) and the non-absorbable group (n = 158). The incisional hernia rate was higher in the fast-absorbable group than in the non-absorbable group (13.9% vs. 6.3%; P = 0.04). The median time to develop an incisional hernia was significantly shorter in the fast-absorbable group (6.7 months vs. 12.3 months; P < 0.01). The incidence of surgical site infection was not different between the two groups, but the incidence of suture sinus was lower in the fast-absorbable group (0% vs. 5.1%; P < 0.01). CONCLUSIONS: The use of fast-absorbable sutures may increase the risk of incisional hernia after laparoscopic colorectal cancer surgery.

Gastrointestinal stromal tumor of the stomach with lymph node metastasis treated by laparoscopic and endoscopic cooperative surgery with lymph node pick-up resection: A case report and literature review.

INTRODUCTION: Gastrointestinal stromal tumor of the stomach with lymph node metastasis is a rare condition, and few cases have been treated by gastrectomy and systematic lymph node dissection. PRESENTATION OF CASE: We report the case of a patient who was treated by local resection with laparoscopic and endoscopic cooperative surgery and lymph node pick-up resection. A 73-year-old woman presented with gastric submucosal tumor and swollen lymph node. The submucosal tumor was 30 mm in size. After surgery, the tumor was confirmed to be a gastrointestinal stromal tumor by immunostaining. No recurrence was noted 36 months following the surgery. DISCUSSION: Laparoscopic and endoscopic cooperative surgery allows minimal resection because the exact resection margin can be identified. Therefore, endoscopy is a useful aid in the treatment of gastric gastrointestinal stromal tumor. The MIB-1 index of metastatic lymph node was lower than that of a primary lesion; hence, the prognosis might not depend on lymph node metastasis. CONCLUSION: Laparoscopic and endoscopic cooperative surgery and lymph node pick-up resection were useful and minimally invasive. Systematic lymph node dissection is not a viable option.

Internal hernia beneath the obturator nerve after robot-assisted lateral lymph node dissection for rectal cancer: A case report and literature review.

A 63-year-old man who underwent robot-assisted laparoscopic low anterior resection and right lateral lymph node dissection (LLND) for rectal cancer presented with right thigh pain, nausea, vomiting, and abdominal pain on postoperative day 17. CT revealed dilated small bowel in the pelvis, and a small bowel loop was detected outside the internal iliac artery branch. Emergent laparoscopic surgery revealed the migration of the small bowel into the space beneath the right obturator nerve. The herniated bowel was reduced, and the obturator nerve was sharply dissected from the herniated bowel and preserved. The hernial orifice was left unrepaired. Postoperative recovery was uneventful, and the right thigh pain disappeared. It is important to consider the possibility of internal herniation beneath the obturator nerve after minimally invasive lateral lymph node dissection for rectal cancer.

A rare case of peritoneal deposits with carbon pigmentation after preoperative endoscopic tattooing for sigmoid colon cancer.

PURPOSE: We report a case in which pigmented peritoneal deposits were found during laparoscopic surgery following preoperative endoscopic tattooing for sigmoid colon cancer. METHODS: The patient's clinical, endoscopic, and histological data from the Niigata City General Hospital were reviewed, as well as the literature on laparoscopic surgery involving the preoperative endoscopic tattoo, with a focus on the relevance of peritoneal deposits and tattooing ink. RESULTS: A 71-year-old man presented to our hospital complaining of vomiting and abdominal distention. Abdominal computed tomography revealed obstructive sigmoid colon cancer. An emergency endoscopic colon stenting procedure and injection of 0.2 ml India ink to the submucosal layer of the tumor's anal side were performed. Laparoscopic-assisted sigmoid colectomy was done 14 days after stenting. At surgery, seven small peritoneal deposits were seen in the rectovesical pouch and at the site adjacent to the tumor. All peritoneal deposits were stained by the ink. Gross leakage of the ink into extraintestinal sites was seen. The seven peritoneal deposits were resected under laparoscope. Histological findings revealed that the seven peritoneal deposits were composed of adenocarcinoma and carbon pigments. Immunohistochemical staining for cluster of differentiation 163 showed that the carbon pigments in the peritoneal deposits were within macrophages. CONCLUSIONS: The possibility of the tattooing procedure causing peritoneal dissemination cannot be completely denied, but it can be hypothesized that the carbon pigmentation was transferred to peritoneal deposits by macrophages. In the future, we hope that this phenomenon becomes a keystone for diagnoses and treatments for peritoneal dissemination.

Use of indocyanine green fluorescence imaging to determine the area of bowel resection in non-occlusive mesenteric ischemia: A case report.

INTRODUCTION: Non-occlusive mesenteric ischemia (NOMI) is a type of acute intestinal ischemia, and its associated mortality is very high. In laparotomy of NOMI, we often have difficulty determining the area of bowel resection. We herein describe a case in which we detected the area of bowel resection using indocyanine green (ICG) fluorescence imaging. PRESENTATION OF THE CASE: An 89-year-old man diagnosed as having advanced gastric cancer underwent distal gastrectomy. On the night of postoperative day 4, he strongly complained of distention of the abdomen. The laboratory data indicated severe metabolic acidosis and dehydration. The abdominal computed tomography scan showed a dilated small bowel, but there were no specific signs suggestive of bowel necrosis. We suspected NOMI and decided to perform emergency laparotomy because we could not exclude the possibility of bowel necrosis. During the operation, we could not detect the necrotic bowel macroscopically. After injecting 2.5 mg of ICG, the ischemic area of the bowel became visible as a region with poor fluorescence emission using the Photodynamic Eye™ (Hamamatsu Photonics K.K.). We resected the ischemic bowel and performed anastomosis. We confirmed that he was alive at 4 months after the operation of NOMI. CONCLUSION: Intraoperative ICG fluorescence imaging makes it possible to detect necrotic intestine that cannot be found with the naked eye. By using this method, planned reoperation to find any newly developed necrotic intestine might be unnecessary. Intraoperative ICG fluorescence imaging is useful for defining the area of ischemic bowel in a patient with NOMI.

Comparison of perioperative and oncological outcome of thoracoscopic esophagectomy in left decubitus position and in prone position for esophageal cancer.

PURPOSE: The aim of this study was to clarify the differences between thoracoscopic esophagectomy in the left decubitus position (LP) and in the prone position (PP) in terms of short-term perioperative outcomes and long-term oncological outcomes after more than 5 years of follow-up. METHODS: Patients with esophageal cancer who underwent thoracoscopic esophagectomy and were followed up for more than 5 years were analyzed retrospectively. Of 142 patients, 72 underwent LP esophagectomy and 70 underwent PP esophagectomy. Operation time, blood loss, operative morbidity, mortality, length of hospital stay, and the number of dissected lymph nodes were compared to evaluate short-term outcomes. Cancer recurrence and overall survival were compared to examine long-term outcomes. RESULTS: Patient and tumor characteristics were not different between the LP and PP groups except for the rate of neoadjuvant chemotherapy. Blood loss was significantly lower in the PP group than in the LP group. Incidence of Clavien-Dindo (C.D.) grade ≥ III complications was significantly lower in the PP group than in the LP group. Pulmonary complications were also significantly lower in the PP group than in the LP group. Operation type (LP versus PP) was identified as an independent risk factor for pulmonary complications (odds ratio 0.27, p = 0.03) by multivariate analysis. Cancer recurrence rate, initial recurrence site, and overall survival rate were not different between the two groups. CONCLUSIONS: PP is regarded as a less invasive procedure than LP with the same oncological effect.

Safety and efficacy of a novel continuous incision technique for laparoscopic transcystic choledocholithotomy.

INTRODUCTION: The purpose of this study was to evaluate the safety and efficacy of a novel continuous incision technique for the cystic duct and the bile duct over the orifice for laparoscopic transcystic choledocholithotomy (LTCL). METHODS: LTCL was attempted in 103 consecutive patients from January 1998 to March 2015 and was successful in 96 patients. The cystic duct confluence was made by cutting upward from the orifice in 19 patients. The cystic duct was incised downward beyond the orifice to the bile duct in the other 77 patients. Both of these procedures involved LTCL. RESULTS: LTCL was successful in 96 patients. It failed in seven patients because of large bile duct stones (BDS), left lateral entry of the cystic duct, or the cystic duct's small diameter. The success rates of LTCL were 98% (47/48), 96% (42/44), and 64% (7/11) for patients with BDS <10 mm, 10-20 mm, and ≥20 mm, respectively. The success rate for removing BDS <20 mm was significantly higher than the removal rate for BDS ≥20 mm (P < 0.0001). There was no significant difference between the incidences of complications associated with BDS ≥10 mm and with BDS <10 mm (P = 0.49). In those who underwent successful LTCL, complications occurred in 3 of 23 patients with failed preoperative duodenoscopic sphincterotomy and in 9 of the other 73 patients; the incidence of complications did not significantly differ between these groups (P = 0.93). CONCLUSION: LTCL is safe and feasible for exploration of the bile duct and removal of BDS <20 mm.