1. Shu-Hung, Chuang, MD1,2, Chih-Sheng Lin, PhD2
Single-incision Laparoscopic Common Bile Duct Exploration With Conventional Instruments: An Innovative Technique and Preliminary Comparative Study
Shu-Hung, Chuang, MD1,2, Chih-Sheng Lin, PhD2
Department of Surgery, Mackay Memorial Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
Department of Biological Science and Technology, National Chiao Tung University, Hsin-Chu, Taiwan

2. Background
Single-incision laparoscopic surgery (SILS) or laparoendoscopic single-site (LESS) surgery has been applied in various fields in recent two decades
Single-incision laparoscopic cholecystectomy (SILC) is the mostly published SILS to date※
※The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review. Ahmed K et al. Surg Endosc, 2011.

3. Background
The present documentation about single incision laparoscopic common bile duct exploration (SILCBDE) is sparse.
Laparoendoscopic single-site common bile duct exploration using the manual manipulator. Shibao K et al. Surg Endosc, 2013 – 13 cases
Single-incision laparoscopic cholecystectomy with routine intraoperative cholangiography and common bile duct exploration via the umbilical port. Yeo D et al. Surg Endosc, 2012 – 4 cases

4. Methods – Chart Review From Oct. 2011 to Jan. 2013
29 consecutive patients underwent LC and LCBDE by a single surgeon:
17 three or four-incision (standard) LC and LCBDE
12 SILC and SILCBDE
Exclusion criteria – Mirizzi syndrome, liver cirrhosis with portal hypertension
Statistics – Pearson's chi-square test, Student’s t-test

5. Surgical Techniques

6. SILC
Skin incision ports insertion※ lateral view※
※From multi-incision laparoscopic cholecystectomy to single-incision laparoscopic cholecystectomy step-by-step: one surgeon’s self-taught experience and retrospective analysis. Chuang SH. Asian J Surg, 2013

7. SILCBDE – Port Insertion
skin incision ports insertion
Vertical arrangement of ports – to facilitate horizontal movement
Interlaced position of trocars with different lengths – to reduce collisions

8. Choledochoscope Manipulation
Wrapped tip of choledochoscope
choledochoscope manipulation lateral view
Wrapping the choledochoscope tip with Steri-StripsTM (3M corporate, the United States) – to avoid coating damage
Be gentle and precise!

9. Bile Duct Closure Catching less tissue to prevent CBD stricture
Suturing with close inter-stitch space (nearly 1 stitch per 1 mm) to prevent bile leakage
Leakage test via transcystic tube by saline flushing

10. Cholangiogram
(A, B) Intra-operative cholangiograms, (C, D) Completion cholangiograms – to replace the traditional post-operative T-tube cholangiogram.

11. 2-2.5 cm Incision

12. Results

13. Table 1. Patient characteristics
Standard LCBDE (n=17)
SILCBDE (n=12) P
Age (y)
46.6 ± 15.4
46.3 ± 16.4
0.966
Gender (M:F)
7:10
7:5
0.362
Body mass index (kg/m2)
25.97 ± 3.26
24.88 ± 3.61
0.406
Modified APACHE II score※, n (%)
0.393
0-5, low risk
16 (94.1)
12 (100)
6-9, intermediate risk
1 (5.9)
10-11, high risk
ASA classification, n(%)
0.301 1
3 (25.0) 2
13 (76.5)
8 (66.7) 3
3 (17.6)
1 (8.3) ≧4
Comorbidity, n (%)
5 (29.4)
2 (16.7)
0.430
Previous abdominal operation, n (%)
ASA, American Society of Anesthesiologists.
※Proposed classification of complications of surgery with examples of utility in cholecystectomy. Clavien PA et al. Surgery, 1992.

14. Table 2. Clinical presentations
Standard LCBDE (n=17)
SILCBDE (n=12) P
Jaundice, n (%)
8 (47.1)
8 (66.7)
0.296
Acute cholecystitis, n (%)
6 (35.3)
11 (91.7)
0.002＊＊
Pancreatitis, n (%)
3 (17.6)
0.124
Acute cholangitis, n (%)
4 (23.5)
1 (8.3)
0.286
WBC count ≧ 11,000 mm3, n (%)
Abnormal liver function tests, n (%)
15 (88.2)
0.765
Common bile duct diameter (mm)
9.35 ± 3.00
10.00 ± 2.76
0.556
Known bile duct stone, n (%)
5 (29.4)
5 (41.7)
0.494
Suspicious bile duct stone, n (%)
12 (70.6)
7 (58.3)
＊＊P < 0.01.

15. Table 3. Operative modifications and results
Standard LCBDE (n=17)
SILCBDE (n=12) P
Bile duct exploration route, n (%)
0.051
Transcystic
7 (41.2)
1 (8.3)
Choledochotomy
10 (58.8)
11 (91.7)
Completion cholangiogram, n (%)
17 (100)
10 (83.3)
0.081
Stone clearance, n (%)
16 (94.1)
12 (100)
0.393
Number of stone extracted
1.4 ± 0.8
2.7 ± 4.3
0.316
Gallbladder pathology, n (%)
0.002＊＊
Gangrene/empyema
3 (17.6)
Acute inflammation
Mild acute/chronic inflammation
11 (64.7)
Operative time (min)
237.1 ± 58.9
269.3 ± 60.7
0.164
Estimated blood loss (ml)
31.2 ± 57.6
35.0 ± 53.6
0.858
Pethidine dose (mg/kg)
0.959 ± 1.292
0.732 ± 0.607
0.577
Post-operative length of hospital stay (d)
4.8 ± 2.5
3.8 ± 1.5
0.215
Conversion, n (%)
0.226
Standard LCBDE —
Open LCBDE
Complication, n (%)
2 (11.8)＃
1 (8.3)※
0.765
＊＊P < ＃One was minor bile leakage and infected subphrenic collection; the other was minor bile leakage. ※Minor bile leakage and self-limited duodenal ulcer hemorrhage.

16. Conversion Standard LCBDE – nil
SILCBDE – one case (8.3 %) was converted to standard LCBDE
No procedure was converted to an open operation.

17. Complication Standard LCBDE – two cases (11.8 %)
Self-limited minor bile leakage and infected subphrenic collection which was managed by echo-guided pigtail drainage
Self-limited minor bile leakage
SILCBDE – one case (8.3 %)
Self-limited minor bile leakage and duodenal ulcer hemorrhage

18. Conclusions
SILCBDE with conventional instruments is as safe and efficacious as standard LCBDE for choledocholithiasis in experienced hands.
Key points – choledochoscope manipulation and bile duct closure.

19. Video: SILCBDE

20. Thank You for Your Attention