1. Laparoscopic common bile duct exploration 腹腔鏡總膽管探查術 奇美醫學中心 溫義輝

2. Introduction Biliary T-tube after choledochotomy Biliary T-tube after choledochotomy –Advantage: for decompression / cholangiography / retrieval of retained stone –Disadvantage: high complication rate (15.3%)*, technical requirement (laparoscopic T-tube placement and suturing) *ANZ J of Surgery 2002

3. Purpose Retrospective comparison of the results of laparoscopic versus open choledochotomy to seek methods of prevention of T-tube related complications and check the strategy of T-tube free approach. Retrospective comparison of the results of laparoscopic versus open choledochotomy to seek methods of prevention of T-tube related complications and check the strategy of T-tube free approach.

4. Indication for laparoscopic choledochotomy Indication for laparoscopic choledochotomy –Stone not suitable TCyD approach (CHD stone, stone large than CyD, CyD-CBD junction prevent easy access to the CBD) –CBD diameter > 8mm –CBD stone number < 10 Contraindication for laparoscopic choledochotomy Contraindication for laparoscopic choledochotomy –Large / impacted / too many stones in CBD (CHD) –s/p exploratory laparotomy Material and Methods

6. Procedures of laparoscopic choledochotomy 1. LC with routine use of IOC 2. Choledochotomy: electrical cauterization (fine needle / low electric diathermy current) 3. Choledocholithotomy: choledochoscopy (EHL) 4. Placement of T-tube: tailored T-tube with split arm 5. Suturing of CBD 6. Transfixing sutures (3-0 plain catgut) 7. Completion cholangiography if indicated

7. Methods of choledochotomy Pt. characteristics Laparoscopic(n=56)Open(n=68) Age (year) 56 ±14.2 54 ±12.0 Sex (M/F) 20/3628/40 s/p PTGBD/PTCD 1823 Acute cholecystitis 2026 Suspected/unsuspected CBD stones CBD stones41/1549/19 Stone number 5±3.2 6 ±2.4 Stone size (cm)* 0.5~1.50.6~1.8 *individual stone All these parameters were not significantly different Result (I)

8. Methods of choledochotomy Laparoscopic(n=56)Open(n=68) Failure 3 ( 5.4%) 0 small caliber CBD small caliber CBD1 huge stone volume huge stone volume1 failure of T-tube placement failure of T-tube placement1 Operative duration (min)* 90 ±18.6* 70 ±12.3* Mean hospital stage (day)* 5 ± 1.2 7 ±2.5 *p<0.05 Result (II)

9. Methods of choledochotomy Laparoscopic (n=56) Open (n=68) Retained stones § * 6 (10.7%)* 2 * IHD stones IHD stones 3 2 CBD microlithiasis CBD microlithiasis 3 0 Morbidity Non T-tube related Non T-tube related13 retention of wound drain retention of wound drain 1 0 wound infection wound infection 0 3 T-tube related* T-tube related* 8 (11.8%)* 1* biliary leakage biliary leakage 1 1 dislodge of T-tube dislodge of T-tube 4 0 disruption of T-tube disruption of T-tube tract (with bile tract (with bile peritonitis) peritonitis) 3 0 § detected by routine post-operative cholangiographic and chole- dochoscopic examination * p<0.05 Result (III)

10. Complications (No. of Pts) ManagementOutcome Retained stones (7) Choledochoscopic retrieval Success Early bile leakage (1) Correction of T-tube axis Improved Disruption of T-tube tract with biliary peritonitis (3) Endoscopic placement of drainage tube Improved Outcome of biliary complication after laparoscopic choledochotomy

11. Discussion(I) In this study, almost laparoscopic choledochotomy were successfully completed, but there were significantly higher incidence of retained stones and T-tube related complication. In this study, almost laparoscopic choledochotomy were successfully completed, but there were significantly higher incidence of retained stones and T-tube related complication.

12. Discussion(II) In case needing T-tube drainage, the technique of choledochotomy and T-tube placement should be familiarized (including incision of small caliber CBD, indwelling o tailored T-tube with split arm and fixation of T-tube), and the quality of T-tube should be properly selected (Latex > Silicon). In case needing T-tube drainage, the technique of choledochotomy and T-tube placement should be familiarized (including incision of small caliber CBD, indwelling o tailored T-tube with split arm and fixation of T-tube), and the quality of T-tube should be properly selected (Latex > Silicon).

13. Discussion(III) In case suitable for T-tube-free laparoscopic choledochotomy, stone clearance should be aggressively attempted and definitely confirmed by thorough choledochoscopic examination and standard completion cholangiography. In case suitable for T-tube-free laparoscopic choledochotomy, stone clearance should be aggressively attempted and definitely confirmed by thorough choledochoscopic examination and standard completion cholangiography.

14. Conclusion 1. Single stage laparoscopic choledochotomy, including laparoscopic cholecystectomy and choledocholithotomy is feasible and safe for patients with CBD stones. 2. T-tube related complications should be prevented in laparoscopic choledochotomy with T-tube drainage procedures and duct clearance should be confirmed in T-tube free procedures.