The effects of previous abdominal surgery and the utilisation of modified access techniques on the operative difficulty and outcomes of laparoscopic cholecystectomy and bile duct exploration.

BACKGROUND: Early reports suggested that previous abdominal surgery was a relative contraindication to laparoscopic cholecystectomy (LC) on account of difficulty and potential access complications. This study analyses different types/systems of previous surgery and locations of scars and how they affect access difficulties. As modified access techniques to minimise risk of complications are under-reported the study details and evaluates them. METHOD: Prospectively collected data from consecutive LC and common bile duct explorations (LCBDE) performed by a single surgeon over 30 years was analysed. Previous abdominal surgery was documented and peri-operative outcomes were compared with patients who had no previous surgery using Chi-squared analysis. RESULTS: Of 5916 LC and LCBDE, 1846 patients (31.2%) had previous abdominal surgery. The median age was 60 years. Those with previous surgery required more frequent duodenal (RR 1.07; p = 0.023), hepatic flexure (RR 1.11; p = 0.043) and distal adhesiolysis (RR 3.57; p < 0.001) and had more access related bowel injuries (0.4% vs. 0.0%; p < 0.001). Previous upper gastrointestinal and biliary surgery had the highest rates of adhesiolysis (76.3%), difficult cystic pedicles (58.8%), fundus-first approach (7.2%), difficulty grades (64.9% Grades 3-5) and utilisation of abdominal drains (71.1%). Previous open surgery resulted in longer operative time compared to previous laparoscopic procedures (65vs.55 min; p < 0.001), increased difficulty of pedicle dissection (42.4% vs. 36.0%; p < 0.05) and required more duodenal, hepatic flexure and distant adhesiolysis (p < 0.05) and fundus-first dissection (4% vs 2%; p < 0.05). Epigastric and supraumbilical access and access through umbilical and other hernias were used in 163 patients (8.8%) with no bowel complications. CONCLUSION: The risks of access and adhesiolysis in patients with previous abdominal scars undergoing biliary surgery are dependent on the nature of previous surgery. Previous open, upper gastrointestinal and biliary surgery carried the most significant risks. Modified access techniques can be adopted to safely mitigate these risks.

Utilization of Laparoscopic Choledochoscopy During Bile Duct Exploration and Evaluation of the Wiper Blade Maneuver for Transcystic Intrahepatic Access.

OBJECTIVE: This study aims to examine the indications, techniques, and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the wiper blade maneuver (WBM) for transcystic intrahepatic choledochoscopy. SUMMARY OF BACKGROUND DATA: Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particularly with the increasing role of transcystic exploration. METHODS: The indications, techniques, and operative and postoperative data on choledochoscopy collected prospectively during transcystic and choledo- chotomy explorations were analyzed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochoscopes. RESULTS: Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during 1320 bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilized more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts, and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. Twenty retained stones (2.1%) were encountered but no choledochoscopy related complications. CONCLUSIONS: Choledochoscopy should always be performed during a chol- edochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilized in over 50% of explorations, increasing their rate of success. When attempted, the transcystic WBM achieves intrahepatic access in 70%-80%. It should be part of the training curriculum.

A proposed difficulty grading system for laparoscopic bile duct exploration: benefits to clinical practice, training and research.

BACKGROUND: A gap remains between the mounting evidence for single session management of bile duct stones and the adoption of this approach. Laparoscopic bile duct exploration (LBDE) is limited by the scarcity of training opportunities and adequate equipment and by the perception that the technique requires a high skill-set. The aim of this study was to create a new classification of difficulty based on operative characteristics and to stratify postoperative outcomes of easy vs. difficult LBDE irrespective of the surgeon's experience. METHODS: A cohort of 1335 LBDEs was classified according to the location, number and size of ductal stones, the retrieval technique, utilisation of choledochoscopy and specific biliary pathologies encountered. A combination of features indicated easy (Grades I and II A & B) or difficult (Grades III A and B, IV and V) transcystic or transcholedochal explorations. RESULTS: 78.3% of patients with acute cholecystitis or pancreatitis, 37% with jaundice and 46% with cholangitis had easy explorations. Difficult explorations were more likely to present as emergencies, with obstructive jaundice, previous sphincterotomy and dilated bile ducts on ultrasound scans. 77.7% of easy explorations were transcystic and 62.3% of difficult explorations transductal. Choledochoscopy was utilised in 23.4% of easy vs. 98% of difficult explorations. The use of biliary drains, open conversions, median operative time, biliary-related complications, hospital stay, readmissions, and retained stones increased with the difficulty grade. Grades I and II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V. There were 2 deaths in difficulty Grade V and one in Grade IIB. CONCLUSION: Difficulty grading of LBDE is useful in predicting outcomes and facilitating comparison between studies. It ensures fair structuring and assessment of training and progress of the learning curve. LBDEs were easy in 72% with 77% completed transcystically. This may encourage more units to adopt this approach.

Laparoscopic bile duct exploration during pregnancy: a multi-center case series and literature review.

BACKGROUND: The physiological changes of pregnancy increase the risk of gallstone formation and choledocholithiasis. Traditionally, endoscopic retrograde cholangiopancreatography (ERCP) has been the main approach for managing choledocholithiasis during pregnancy, but recent progress in laparoscopic bile duct exploration (LBDE) has demonstrated this technique as a safe and effective alternative option. METHODS: A retrospective multicenter study of all patients who underwent LBDE during pregnancy from five centers with proven experience in LBDE between January 2010 and June 2020 was performed. The primary endpoint was to analyze the role of LBDE during pregnancy and to further characterize its position as a safe and effective alternative for the management of choledocholithiasis. A systematic review of the published literature relating to LBDE during pregnancy until February 2022 was also performed. RESULTS: Five institutions reported performing LBDE during pregnancy in 8 patients. Median surgical time was 75 min (range: 60-140 min). The bile duct was cleared successfully in all patients, and the median hospital stay was 2 days (range: 1-3 days). The literature review identified a total of 7 patients with a successful CBD clearance rate of 86%. There were no major maternal, fetal, or pregnancy-related complications in any of the total 15 patients included. The symptomatic common bile duct lithiasis with deranged liver function tests was the most frequent indication (n=7). CONCLUSION: LBDE during pregnancy appears to be safe and effective. More evidence reporting outcomes of LBDE during pregnancy is needed before any strong recommendations can be made.

Conventional Surgical Management of Bile Duct Stones: A Service Model and Outcomes of 1318 Laparoscopic Explorations.

OBJECTIVE: The primary aim of this study was to describe the service model of one-session management, with a limited role for preoperative endoscopic clearance. The secondary aim was to review the outcomes and long term follow up in comparison to available studies on LCBDE. BACKGROUND: The laparoscopic era brought about a decline in the conventional surgical management of common bile duct stones. Preoperative endoscopic removal became the primary method of managing choledocholithiasis. Although LCBDE deals with gallstones and ductal stones in onw session, the limited availability of such an advanced procedure perpetuated the reliance on the endoscopic approach. METHODS: Prospective data was entered into a single surgeon's database containing 5739 laparoscopic cholecystectomy over 28 years and analyzed. RESULTS: One thousand eighteen consecutive LCBDE were included (23% of the series). Intraoperative cholangiography was performed in 1292 (98.0%). The median age was 60 years, male to female ratio 1:2 and 75% were emergency admissions. Most patients (43.4%) presented with jaundice. 66% had transcystic explorations and one third through a choledochotomy with 2.1% retained stones, 1.2% conversion, 18.7% morbidity, and 0.2% mortality. Postoperative ERCPs were needed in 3.1%. Recurrent stones occurred in 3%. CONCLUSIONS: One stage LCBDE is a safe and cost-effective treatment where the expertise and equipment are available. Endoscopic treatment has a role for specific indications but remains the first-line treatment in most units. This study demonstrates that establishing specialist services through training and logistic support can optimize the outcomes of managing common bile duct stones.

The incidence, operative difficulty and outcomes of staged versus index admission laparoscopic cholecystectomy and bile duct exploration for all comers: a review of 5750 patients.

BACKGROUND: The timing of laparoscopic cholecystectomy (LC) for emergency biliary admissions remains inconsistent with national and international guidelines. The perception that LC is difficult in acute cholecystitis and the popularity of the two-session approach to pancreatitis and suspected choledocholithiasis result in delayed management. METHODS: Analysis of prospectively maintained data in a unit adopting a policy of "intention to treat" during the index admission. The aim was to study the incidence of previous biliary admissions and compare the operative difficulty, complications and postoperative outcomes with patients who underwent index admission LC. RESULTS: Of the 5750 LC performed, 20.8% had previous biliary episodes resulting in one admission in 93% and two or more in 7%. Most presented with biliary colic (39.6%) and acute cholecystitis (27.6%). A previous biliary history was associated with increased operative difficulty (p < 0.001), longer operating times (86.9 vs. 68.1 min, p < 0.001), more postoperative complications (7.8% vs. 5.4%, p = 0.002) and longer hospital stay (8.1 vs. 5.5 days, p < 0.001) and presentation to resolution intervals. However, conversion and mortality rates showed no significant differences. CONCLUSION: Index admission LC is superior to interval cholecystectomy and should be offered to all patients fit for general anaesthesia regardless of the presenting complaints. Subspecialisation should be encouraged as a major factor in optimising resource utilisation and postoperative outcomes of biliary emergencies.

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients.

BACKGROUND: Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients' quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE. METHODS: A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined. RESULTS: Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths. CONCLUSION: This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.

Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates.

BACKGROUND: Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. METHODS: Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. RESULTS: 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. CONCLUSION: Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.

Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies.

PURPOSE: The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies. METHODS: A prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series. RESULTS: Twenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured. CONCLUSION: Ligation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.

Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for biliary emergencies: a service model.

AIMS: The rate of acute laparoscopic cholecystectomy remains low due to operational constraints. The purpose of this study is to evaluate a service model of index admission cholecystectomy with referral protocols, refined logistics and targeted job planning. METHODS: A prospectively maintained dataset was evaluated to determine the processes of care and outcomes of patients undergoing emergency biliary surgery. The lead author has maintained a 28 years prospective database capturing standard demographic data, intraoperative details including the difficulty of cholecystectomy as well as postoperative outcome parameters and follow up data. RESULTS: Over five thousand (5555) consecutive laparoscopic cholecystectomies were performed. Only patients undergoing emergency procedures (2399,43.2% of entire group) were analysed for this study. The median age was 52 years with 70% being female. The majority were admitted with biliary pain (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgeons. 80% underwent surgery within 5 days (40% within 24 h). Cholecystectomies were performed on scheduled lists (44%) or dedicated emergency lists (29%). Two thirds had suspected bile duct stones and 38.1% underwent bile duct exploration. The median operating time was 75 min, median hospital stay 7 days, conversion rate 0.8%, morbidity 8.9% and mortality rate 0.2%. CONCLUSION: Index admission cholecystectomy for biliary emergencies can have low rates of morbidity and mortality. Timely referral and flexible theatre lists facilitate the service, optimising clinical results, number of biliary episodes, hospital stay and presentation to resolution intervals. Cost benefits and reduced interval readmissions need to be weighed against the length of hospital stay per episode.

Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure.

BACKGROUND: Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies. AIMS AND METHODS: A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely. RESULTS: The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions. CONCLUSION: All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered.

One-session laparoscopic management of Mirizzi syndrome: feasible and safe in specialist units.

BACKGROUND: To evaluate the laparoscopic management of Mirizzi syndrome, seldom diagnosed preoperatively causing difficulty when performing cholecystectomy and increasing complication risks. METHODS: Analysis of a prospective single-surgeon database of 5700 laparoscopic cholecystectomies found 58 Mirizzi syndrome cases. They were managed with an intention to treat during the index admission according to protocol of single-session management of bile duct stones. RESULTS: 38/58 patients were females (65.5%). The median age was 55 years. 53 cases were emergency admissions. 34 cases (58.6%) only had ultrasound scanning. Operative difficulty was Grade IV in 34 cases (58.6%) and Grade V in 20 (34.5%) (Nassar Scale). There were 33 Mirizzi Type IA, 7 Type IB, 16 Type II and one each of Type III and Type IV. Bile duct exploration was performed in 94.8% through choledochotomy/ transfistula in 58.6% or transcystic in 36.2%. Four cases required conversion to open. Postoperative morbidity occurred in 29%. Two 30-day mortalities occurred from pneumonia in two elderly patients who were late referrals. CONCLUSION: Although the utilization of the laparoscopic approach in managing bile duct stones is not currently widely practiced it was safer in this series than in reported series of open surgery in Mirizzi Syndrome. The optimal approach to Mirizzi Type II is via cholecystocholedochal fistula to explore the bile duct then drain with T-tube through the fistula. It is unnecessary to perform bilioenteric bypass in majority of cases, reducing the morbidity and mortality.

Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system.

BACKGROUND: The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale. METHOD: Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets. RESULT: Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773-0.806, p < 0.001) on external validation, with 11.0% versus 80.0% of patients classified as low versus high risk having difficult surgeries. CONCLUSION: We have developed and validated a pre-operative scoring system that uses easily available pre-operative variables to predict difficult laparoscopic cholecystectomies. This scoring system should assist in patient selection for day case surgery, optimising pre-operative surgical planning (e.g. allocation of the procedure to a suitably trained surgeon) and counselling patients during the consent process. The score could also be used to risk adjust outcomes in future research.

Correction to: Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy.

The list of the CholeS management group, Collaborators and Data Validators were omitted from the Acknowledgments.

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy.

BACKGROUND: A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. METHODS: Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall's tau for dichotomous variables, or Jonckheere-Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. RESULTS: A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). CONCLUSION: We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty.

Fluorocholangiography: reincarnation in the laparoscopic era-evaluation of intra-operative cholangiography in 3635 laparoscopic cholecystectomies.

BACKGROUND: The introduction of laparoscopic cholecystectomy (LC) resulted in the decline of routine intra-operative cholangiography (IOC). Common bile duct stones are being diagnosed preoperatively using magnetic resonance cholangiopancreatography (MRCP). We aim to evaluate the use and benefits of IOC during laparoscopic biliary surgery at a high-volume biliary surgery unit. METHODS: Prospective data from 4088 patients undergoing LC over 22 years were analysed. Referral protocols allow one firm to receive the great majority of biliary emergencies and all suspected ductal stones. All patients with gall stones on ultrasound scanning, fit for surgery, will undergo LC during the index admission. MRCP and ERCP are not part of preoperative investigation. A four-port LC is performed with a size 5Fr ureteric catheter within an open cannula to obtain an IOC through right sub-costal port. RESULTS: Of 4088 patients, IOC was attempted in 3691 (90.2 %) and 3635 had a successful IOC (98.4 %). 75 % were females. The mean age was 59 years. Patients presented with one or more of the following: chronic biliary pain in 60 %, acute pain 26.7 %, acute cholecystitis 8.4 %, gallstone pancreatitis 7.8 % and jaundice with or without cholangitis in 19.2 %. A total of 1328 patients (36.5 %) had risk factors for CBD stones. The IOC was abnormal in 975 cases (26.8 %), recording 1599 abnormalities. IOC identified 774 patients with CBD stones (21.3 %), including previously unsuspected CBD stones in 4.7 %. IOC was false negative in 20 cases (0.5 %) found to have stones on basket exploration. A decision not to perform IOC in 453 cases (11 %) was made preoperatively in 74.2 % and intra-operatively in 12.3 %. CONCLUSION: IOC can be safely and routinely performed in LC. It helps to identify CBD stones, even in patients with no known risk factors, delineate bile duct anatomy and facilitate single-stage management of CBD stones.

Basket-in-catheter access for transcystic laparoscopic bile duct exploration: technique and results.

BACKGROUND: When common bile duct (CBD) stones are detected during laparoscopic cholecystectomy, the insertion of baskets via the cystic duct (CD) can be difficult and may occasionally cause complications. We introduced a new technique 'basket in catheter' (BIC) for transcystic CBD exploration. METHODS: Although cannulating the CD using a cholangiography catheter is successful in most cases, it may occasionally be difficult. Cystic duct anatomy may prevent the usually stiffer sharper tip of the basket, from entering the CBD, resulting in failure, perforation or a false passage. In the majority of our cases, the cholangiography catheter (CC) is not withdrawn from the duct should the intraoperative cholangiography show CBD stones. The tip of a basket is inserted into the CC and advanced to a predetermined distance, allowing the tip of the basket to exit the end of the CC into the CBD. The basket is then opened, advanced to feel the lower end and manipulated to trap the stone. The common hepatic duct is compressed gently to prevent stones from slipping upwards. The catheter and basket are pulled back together to extract the stone. RESULTS: We have used this technique in 274 cases since 2010. The rate of transcystic versus choledochotomy stone extraction has increased, saving unnecessary choledochotomies. The percentage of transcystic exploration increased from 55 % for the period 2005-2009 to 70 % for the period 2010-2014. There were no conversions to open surgery and no retained stones. The morbidity rate was 4.0 % with no mortality. CONCLUSIONS: We demonstrate a technique to facilitate the insertion of extraction baskets into the common bile duct using the cholangiography catheter as a guide. The 'basket-in-catheter' (BIC) technique for transcystic CBD exploration is easier and safer than inserting the basket alone.

The "Basket-in-Catheter" technique: facilitating transcystic bile duct exploration and optimising the management of suspected ductal stones.

The 'Basket-in-Catheter' (BIC) technique facilitates basket-only laparoscopic transcystic exploration (LTCE), increasing its success rate. Using the cholangiography catheter as a sheath is easier and safer than inserting the wire basket-alone. This study evaluates its benefits in confirmed and suspected ductal stones. Retrospective analysis of prospectively collected data on patients with pre-operative or operative suspicion of bile duct stones or with positive and equivocal intraoperative cholangiographies (IOC) who had LTCE attempted using blind basket trawling, without choledochoscopy, were reviewed. The incidence and outcomes of blind basket LTCEs attempted before and after introducing the BIC technique, whether or not stones were retrieved, were analysed. Blind basket LTCE was attempted in 732 patients. Of 377 (51.5%) patients undergoing successful stone retrieval, only 62% had pre-operative clinical and radiological risk factors for ductal stones, 25% had operative risk factors and 13% had silent stones discovered on IOC. Another 355 patients (48.5%) had negative trawling, although one half had pre-operative risk factors for ductal stones and 47.6% had operative risk factors, e.g. cystic duct stones or dilatation. This cohort had equivocal cholangiography in 25.9%. Following basket trawling, repeat IOC confirmed resolution of abnormalities. As no stones were retrieved, these were not considered duct explorations. The BIC technique facilitates safe and speedy bile duct clearance when stones are confirmed, avoiding choledochotomies, without significant complications. BIC duct trawling is also beneficial in patients with suspected ductal stones, helping to resolve equivocal IOCs. It helps surgeons to acquire and consolidate ductal exploration skills.

Intrahepatic choledochoscopy during trans-cystic common bile duct exploration; technique, feasibility and value.

BACKGROUND: Transcystic laparoscopic common bile duct exploration (TC-LCBDE) is advantageous for exploring the bile duct. Choledochoscopy, however, may be quite challenging to perform transcystically because the cystic duct is usually narrow, duct anatomy may be unfavorable, and not all stones are amenable to transcystic extraction. Convention suggests that it is technically very difficult to visualize the intrahepatic bile ducts with transcystic choledochoscopy, due to the angle of insertion of the cystic into the common bile duct (CBD). However, we have performed intrahepatic choledochoscopy successfully, moving the choledochoscope from the CBD into the common hepatic duct by using what we have termed a "wiper blade maneuver". The purpose of this study was to confirm how often this was possible. METHODS: A search of a prospectively collected database of patients undergoing routine intraoperative cholangiography (IOC) and laparoscopic CBD exploration under the care of a single consultant surgeon was performed. RESULTS: A total of 592 LCBDEs were performed between September 1992 and January 2011; 325 were transcystic explorations. Of these, 72.5 % were female and 56 % were admitted acutely. Exploration and duct clearance was performed by blind Dormia basket trawling in 63 %. The choledochoscope was utilized in 120 cases (37 %). The 3-mm choledochoscope was used in 66 (55 %) and the 5-mm scope in 54 (45 %). Intrahepatic choledochoscopy was performed in 49 patients (40.8 %). Length of surgery was 40-350 min (median 90 min; standard deviation 49 min). CONCLUSIONS: It is technically challenging to perform intrahepatic choledochoscopy with a 3-mm choledochoscope due to its narrow gauge. The more rigid 5-mm scope is thus preferred, but is limited in TCE because its effective use depends on the presence of a dilated cystic duct. Despite the technical limitations of both caliber scopes, we have demonstrated that intrahepatic choledochoscopy during TCE is possible, with each, in 40 % of cases.