The Study Of Laparoscopy In High-level Biliary Surgery

Chapter oneLaparoscopic Hepatectomies with cholangioscopy for HepatolithiasisObjective:To explore the feasibility and therapeutic effect of total laparoscopic hepatectomy (LH) for hepatolithiasis.Methods:From November2003to November2012,75consecutive patients with hepatolithiasis were treated in our institute. Of the75patients with hepatolithiasis,35underwent LH (LH group) and40underwent open hepatectomies (OH group). Operative methods included left lateral lobectomy, left hemihepatecomy, choledochotomy, choledochoscopy and T tube drainage. Clinical data including operation time, intraoperative blood loss, rate of using pain relievers, ambulation time, oral intake time, postoperative complication rate, postoperative hospital stay time, stone clearance and recurrence rate were analyzed and compared between the two groups.Results:The operative methods did not show significant difference between the two groups. The operation time of LH group was longer than that of OH group (205.0±40.9min VS155.0±26.6min, P<0.001) and the hospital stay time of LH group was shorter than that of OH group (12.3±2.6VS15.6±4.3, P<0.001).The intraoperative blood loss of LH group was more than that of OH group (330.0±259.7ml VS151.5±137.0ml, P=0.001).However, no difference was found in blood loss of last10cases between LH group and OH group (81.0±19.7VS78.0±22.0, P=0.752). The rate of using pain relievers in LH group was fewer than that of OH group(0%VS62.5%). Ambulation time (1.5±0.5VS3.6±0.7, P<0.001) and oral intake time (2.4±0.5vs4.0±0.7, P<0.001) of LH group were shorter than those in OH group. No difference was found in postoperative complication rate (2.9%VS16.0%), and stone clearance rate (intermediate rate91.4%VS90%and final rate97.1%VS100%) between the two groups. No perioperative death occurred in ether group.73patients (97.3%) were followed up for5-113months (mean41months), including35in LH group and38in OLH group. No difference was found in operative effect between the two groups(97.1%VS100%). Stone recurrence occurred in2patients of each group.Conclusion:LH combined with choledochoscopy for hepatolithiasis is feasible and safe in selected patients with an equal therapeutic effect to that of traditional open hepatectomies. LH showed advanteages of minimally invasive surgery, such as small incision, less pain, fast recovery, less complications etc. Chapter two Laparoscopic hilar cholangioplasty with pedicled gallbladder flap to treat hepatolithiasis complicated main hepatic duct strictureObjective:The aim of the study was to explore the security and feasibility of laparoscopic hilar cholangioplasty with pedicled gallbladder flap to treat left hepatolithiasis complicated main hepatic duct stricture.Methods:We performed laparoscopic hilar cholangioplasty with pedicled gallbladder flap for five patients who suffered from hepatolithiasis from November2011to February2012. They were all female. The mean age was47.4years (range25-60years). The operative procedures involved laparoscopic choledochotomy, choledochoscopy, patial cholecystectomy, hilar cholangioplasty with pedicled gallbladder flap, T tube drainage. Left lateral lobectomy was performed in three patients. We studied the clinical data of these five patients retrospectively.Results:laparoscopic hilar cholangioplasty with pedicled gallbladder flap was successfully performed in5patients with no conversion to open surgery. There was no death. The mean operation time was274.6±25.4min (range250-310min). The mean intraopetive blood loss was130.0±97.5ml (range50-300ml).None of5patitends needed left hemihepatectomy.2patients had no hepatecomy. Other3patients underwent lateral lobectomy with left medial lobe reserved. Complications occurred in one patient. She suffered delayed abdominal hemorrhage because of spleen injury and pneumonia. She got recovered after a second operation and antibiotics treatment. Other4patients recovered very well without any complication. All patients received postoperative follow-up. The range of follow-up period was13-17months. Postoperative T-tube cholangiography showed no bile duct stricture in5patients. One of these five patients had retained stones because she couldn’t received intraoperative choledoscopy while the choledochoscop broke down on that day. She refused a second choledochoscopy, and she had suffered cholangitis for several times because of the retained stons. The operation effect was bad for her. Other4patients had no symtoms after operation, and the operation effect was excellent for them.Conclusion:Laparoscopic hilar cholangioplasty with pedicled gallbladder flap is a safe and feasible method for hepatolithiasis in selective patients.The operation could eliminate bile duct stricture and could keep normal bile duct anatomy so as to avoid the risk of reflux cholangitis. The operation could avoid unecessary hepatectomies. Hepatolithiasis complicated with main hepatic bile duct stricture was no longer contraindication to laparoscopic surgery. Chapter Three The application of laparoscopy in the treatment for hilar cholangiocarcinoma:a report of3casesObejective:To evaluate the feasibility of laparoscopic radical resection for hilar bile duct tumor.Methods:Total laparoscopic radical resections were carried out in3patients with hilar bile duct tumor. According to Bismuth-Corlette classification, case one fell into type I (he was also complicated with duodenal papillary carcinoma),case two fell into type II. Case three was cystadenoma. Operation procedures conclude extrahepatic duct resections, skeletal clearing technology, left hemihepatectomy, pancreaticoduodenectomy, modified Roux-en-Y cholangiojejunostomy.Results:All operations were completed laparoscopically. Operative time was420min～660min (mean,520min). The blood loss was200ml-500ml (mean,333ml). No patient need blood transfusion. They recovered well without death. One patient had vomitting with suspected edema in the stoma of jejuno-jejunostomy. The third patient had transitory bile leak. They were cured with conservative treatments. They were discharged in10days～23days (mean,16.7days). All three patients survive with disease free until now. The longest survival period is more than7years, and the patient is still alive.Conclusion:Laparoscopic radical resection can be a safe and feasible procedure for hilar bile duct tumor by laparoscopic hepatic experts in selected patients. Some advantages of minimally invasion surgery could be achieved. Chapter Four The application of laparoscopic bile duct repair in the treatment of iatrogenic bile duct injuriesBackground:Bile duct injuries (BDI)are a severe complication in abdominal surgery. BDI will cause serious damage to the patient and greatly increase medical expenses, and are likely to give rise to medical malpractice litigation. The incidence of iatrogenic BDI increased200%-300%in the laparoscopic era compared to that in the age of open surgery. Conversion to open surgery or two-stage operations were often needed when BDI occurred, which would cause more pain to patients. It is worth to explore whether laparoscopic repair are suitable for BDI. The aim of the study is to explore the methods and feasibility of laparoscopic repair and reconstruction for BDI found during operation and in early postoperative period.Methods:From Feburary2002to December2012,12patients with BDI were treated with laparoscopic repairs during operation or in early postoperative period. The clinical data were collected and analyzed.11cases of BDI occurred in laparoscopic cholecystectomies (11/1485,0.74%), the other one case occurred in laparoscopic radical gastrectomy.8patients were male, and4patients were female. The mean age was52.4years (range26-70years).6BDI were mild injuries, and other6BDI were severe injuries (high-level bile duct transection). Wan-Yee Lau classification was used for these12BDI.2cases fell into type I,2into Ⅱ A,2into ⅢA,4into ⅣA,2into ⅣB.10BDI were found during operation, and other2BDI were found on the second day after opration. Methods of BDI were repaired according to type and severity of BDI.Laparoscopic suture and T-tube drainage were carried out in2mild partial common hepatic duct injuries (type ⅡA). Laparoscopic simple suture was performed in one patient with a hole-like injury in the right hepatic duct (type ⅣA). Laparoscopic common bile duct exploration, T-tube drainage, unfastening the thread were performed in one patient whose common bile duct was ligated incorrectly (type ⅢA). Laparoscopic closure by simple suturing was performed in one patient whose aberrant small bile duct at the gallbladder bed of live was injured (type Ⅰ). The retained neck of gallbladder was resected and the ocystic duct was sutured laparoscopically in one patient with retained neck of gallbladder and bile leak. Laparoscopic end-to-end bile duct anastomosis with silicone tube internal drainage were performed in6patients with high-level bile duct transection.Results:Primary repaire of all12BDI were performed laparoscopically without conversion.They recovered very well without any complication. There was no death. The meaan hospital stay was9.25das (range5-15days).12patients received a follow-up from4months to10years.There was no bile duct stricture in the period of follow-up.Patient NO.8had cholangitis. Enhanced computed tomography scan showed mild dilated common bile duct. No bile duct stricture or tumor were found by ERCP. It was consider that the mild dilated common bile duct was caused by inflammatory stricture of Vater’s papilla.The patient was cured with EST. There were no long-term complications such as cholangitis, bile duct stricture in other11patients.Conclusion:Mild BDI could be fixed by laparoscopic simple suture or T tube drainage.Bile duct transection could be reconstructed by bile dut end-to-end anastomosis with silicone tube as stent for internal drainage. Laparoscopic repaire was feasible and effective for BDI. However, it is very difficult and technically demanding. Laparoscopic repair of BDI should be performed by biliary surgery specialist with excellent laparocopic skills.