To evaluate the role of laparoscopic surgery in the treatment of intrahepatic biliary stones, an area that is not well-studied. Subjects and methods: A descriptive crosssectional, retrospective study was carried out on a total of 56 patients. Results: 56 patients with intrahepatic biliary stones underwent laparoscopic surgery. The average age was 54.1 ± 12.17. The number of patients with biliary stones in over 2 segments of liver was 62.5%. The average time of operation was 145 ± 20.37 minutes. The average time of exploration of bile duct was 61.52 ± 33 minutes. The average blood loss was 55.65 ± 17.69 mL. None of the surgeries required conversion to open surgery. Complication rate was 8.9%. The success rate for stone removal was 81.8 - 100% for stones in the larger ducts (hepatic ducts, anterior ducts, posterior ducts and common bile duct) and 0 - 33.3% for stones in the segmental ducts.
Trang 1INITIAL RESULTS OF LAPAROSCOPIC SURGERY FOR TREATMENT OF INTRAHEPATIC BILIARY STONES
Do Son Hai 1 ; Bui Tuan Anh 1
Nguyen Quang Nam 1 ; Geraldine Lei Yanlei 2
SUMMARY
Objectives: To evaluate the role of laparoscopic surgery in the treatment of intrahepatic biliary stones, an area that is not well-studied Subjects and methods: A descriptive cross-sectional, retrospective study was carried out on a total of 56 patients Results: 56 patients with intrahepatic biliary stones underwent laparoscopic surgery The average age was 54.1 ± 12.17 The number of patients with biliary stones in over 2 segments of liver was 62.5% The average time of operation was 145 ± 20.37 minutes The average time of exploration of bile duct was 61.52 ± 33 minutes The average blood loss was 55.65 ± 17.69 mL None of the surgeries required conversion to open surgery Complication rate was 8.9% The success rate for stone removal was 81.8 - 100% for stones in the larger ducts (hepatic ducts, anterior ducts, posterior ducts and common bile duct) and 0 - 33.3% for stones in the segmental ducts The average length of postoperative hospital stay was 8.89 ± 2.1 days Conclusion: Laparoscopic surgery is
a safe and effective method for the treatment of intrahepatic biliary stones However, it should
be combined with electrohydraulic lithotripsy via the Kehr drain postoperatively
* Keywords: Intrahepatic biliary stone; Laparoscopic surgery; Electrohydraulic lithotripsy
INTRODUCTION
Treatment of intrahepatic biliary stones
remains a challenge Laparoscopic surgery
has gained popularity in recent years, but
only few studies have been conducted to
study its role in the treatment of intrahepatic
biliary stones We conduct this study:
To determine the feasibility and effectiveness
of this method
SUBJECTS AND METHODS
1 Subjects
56 patients with intrahepatic biliary
stones underwent laparoscopic surgery
treatment program in Abdominal Surgery Department, 103 Military Hospital from May 2013 to March 2015
* Selection criteria: Only intrahepatic
biliary stones alone or both intrahepatic and extrahepatic biliary stones, standardized technique of surgery, availability of research data
2 Methods
* Research methodology: Descriptive
cross-sectional, retrospective and non-comparative study of prospectively collected data
1 103 Military Hospital
2 National University of Singapore
Corresponding author: Do Son Hai (dosonhai.pr@gmail.com)
Date received: 20/12/2018
Date accepted: 25/01/2019
Trang 2* Research contents:
- Some clinical and subclinical
characteristics: Age, gender, history, site
of intrahepatic stones
- Indications and contraindications:
+ Indication: Only intrahepatic biliary
stones alone or both intrahepatic and
extrahepatic biliary stones; no
contra-indication to surgery, abdominal insufflations
of CO2 and endotracheal anesthesia
+ Contra-indications: Having any contra-
indication to surgery, inability to pump
CO2 into abdomen, inability to tolerate
endotracheal anesthesia
- Techniques:
+ The position of patients, preparation
of instruments, and arrangement of the
surgical team: Patient lies supine on the
operating table withlegs extended The
surgeon stands between the patient’s legs
The first assistant stands on the right side
of the patient and the second assistant
stands on the left side of patient
* Equipments: Surgical instruments
and laparoscopic devices were prepared
preoperatively
* Technique:
- Step 1: Set trocars and establish
pneumoperitoneum via CO2 insufflation
The first 10 mm trocar is on the umbilical
area The second 10 mm trocar is on the
left flank or left upper quadrant The first 5
mm trocar is on the right flank The
second 5 mm trocar is on the epigastric
area The fifth trocar, which is used to
retrieve the removed biliary stones and
insert the Kehr drain, is on the right upper
quadrant near the common bile duct
- Step 2: Locatethe common bile duct
and the entire extrahepatic bile duct
- Step 3: Dissect the common bile duct
and remove any visible stones Further dissect into the common hepatic duct, including the right and/or left hepatic duct Introduce a grasper and a mesh along the common bile duct and retrieve any visible stones in the bile ducts using the grasper through the incision on the common bile duct Open in high position of the bile duct
to take advantage of removing stones + Remove the biliary stones by Randal-Mirrizi forcep which can be introduced intra-abdominally through the trocar openings
on the abdomen
+ Place a catheter into the bile duct and instill water at a sufficiently high pressure to expel the stones
+ Perform electrohydraulic lithotripsy of the remaining stones through a flexible tube + Conduct an endoscopy check to ensure that all the stones in the common bile duct, common hepatic duct and segmental ducts have been removed
- Step 4: Place a 16F Kehr drain into
the common bile duct This can be used for electrohydraulic lithotripsy for deep segmental stones later
- Step 5: End the surgery by closing
the trocar openings on the abdomen + Extra procedures (if indicated): Hepatectomy (cirrhosis, biliary stricture, hepatic abscess), cholecystectomy (gallstones or gallbladder atrophy), choledochojejunostomy if the common bile duct is too narrow
* Indicators to assess surgical outcomes:
Duration of surgery, blood loss, extra procedures (hepatectomy, cholecystectomy, connect bile duct to small intestine),
Trang 3incidence rate, complications, clearance
rate of stone, length of postoperative
hospital stay
* Data processing: Using Epi.info 7.1.5
software
RESULTS AND DISCUSSION
1 Some clinical and subclinical
characteristics
- Number of patients studied: 56
- Age ranged from 28 - 78, with an
average of 54.1 ± 12.17 years old
- Gender: female/male = 30/26 (1.15)
- The position of the intrahepatic biliary
stones
Table 1: Location of intrahepatic biliary
stones
Location of intrahepatic
biliary stones
Number of patients
Rate (%)
The distribution of stones in most
intrahepatic bile ducts was relatively
uniform, with the rate ranging from 19.6 -
33.9% Howerver, segmental ducts I and
IV had lower rate of stone formation at
5.4% and 10.7%, respectively and segmental
duct II had the highest incidence of stone formation at 48.2%
8/56 patients (14.3%) had only intrahepatic stones The number of patients with both intrahepatic stones and common bile duct stones was 41/56 (73.2%) The number of patients with intrahepatic stones, common bile duct stones and gallstones was 7/56 (12.5%)
2 Position of the intrahepatic biliary stones according to segmental ducts
Table 2: Position of the intrahepatic
biliary stones based on the number of ductal segments involved
Position
Number
of patients
Rate (%)
Stones in more than 2 segmental ducts
More patients had stones found in more than 2 segmental ducts compared
to those with stones in just 1 segmental duct (p < 0.01) 62.5% of cases had stones in more than 2 segmental ducts
3 Results of laparoscopic surgery for treatment of intrahepatic billiary stones
* Duration of surgery: Is calculated
from the establishment of pneumoperitoneum
to skin closure of the trocar openings The average operating time was 145 ± 20.37 minutes, with the shortest being
60 minutes and the longest being 280 minutes
By contrast, the average surgical time in Yoong Ki Kim et al’s study was 278.4 - 344.3 minutes [9] However, we did not
Trang 4try to take out all of deep segmental
stones We used electrohydraulic lithotripsy
through the Kehr drain to remove the
remaining stones
ducts: 15 - 155 minutes; average time:
61.52 ± 33 minutes
* Amount of blood lost during surgery:
5 - 160 mL; average: 55.65 ± 17.69 mL
* Rate of conversion to open surgery:
0/56 (0%)
* Extra procedures:
Table 3:
Extra procedures
Number
of patients
Rate (%)
Connect bile duct to
Extra procedures were performed in
12 out of 56 cases (21.5%) In comparison,
the rate of hepatectomy in intrahepatic
stones operation in Ton That Tung’s study
was 16.7% [1], 33.3% in Hyung Jun Kwon’s
[7] and 0.9% in Choi T.K’s 0.9% [5]
4 Surgical complications
Table 4:
Complications Number of
patients
Frequency (%)
Duodenum’s serosa
injury
The rate of surgical complications was 5/56 (8.9%) There were no serious complications According to Dang Tam, 1,123 out of 8,612 patients who underwent biliary stones operation had complications (13%) The mortality rate of open surgical biliary stones was 3 - 11% [2]
* Clearance rate of stone:
Table 5:
Number
of patients
Rate (%)
Common bile duct,
The rates of clearance of stone in large bile ducts (right and left hepatic duct, right anterior duct) were all 100% The rate of right posterior duct was 81.8% The segmental duct I, II, III, VIII had low rate
of clearance Billiary stones in the segmental duct IV, V, VI, VII could not take all out According to some studies, the rate of postoperative unremoved stones in all billiary open approach was generally 8 - 27%, and for intrahepatic
Trang 5stones operation was 46 - 67% [4, 6, 8]
According to Tran Dinh Tho, the rate of
clearance of intrahepatic stones via the
open approach, guided by ultrasound and
biliary endoscopy was 64.2% [3] We
deliberately left stones in more distal
segmental ducts as these stones could be
removed via electrohydraulic lithotripsy
through the Kehr drain after 3 - 4 weeks
postoperatively
The average length of postoperative
hospital stay was 8.89 ± 2.1 days
CONCLUSION
- Laparoscopic surgery for treatment of
intrahepatic biliary stones was feasible:
The operation time was not long, ranging
from 60 - 280 minutes The average time
was 145 ± 20.37 minutes
The average time for locating the main
bile ducts was 61.52 ± 33 minutes Blood
loss was minimal, with the average amount
being 55.65 ± 17.69 mL The conversion
rate to open surgery was 0%
- Laparoscopic surgery for treatment of
intrahepatic biliary stones was effective
and safe: The complication rate was
8.9%, including minor complications that
could be easy to solve, and there were no
major complications Clearance rate of
stones in the large bile ducts was high at
81.8 - 100% Postoperative hospital stay
was short, with an average duration of
8.89 ± 2.1 days 91.1% of patients had
good outcome at discharge Unremoved
stones in some segmental ducts were
taken out using electrohydraulic lithotripsy
through the Kehr drain in 3 - 4 weeks
postoperatively
REFERENCES
1 Bui Tuan Anh Study of percutaneous
biliary drainage technique for treatment of
Hanoi 2008
2 Dang Tam Study the role of
percutaneous transhepatic electrohydraulic lithotripsy Medical Doctor Thesis Hochiminh Medical University 2004
3 Tran Dinh Tho Combine endoscopy and
ultrasound in operation to treat intrahepatic biliary stones Medical Doctor Thesis Hanoi Medical University 2006
4 Aguirre-Olmedo, Adolfo Cuendis-Velazquez
et al Laparoscopic choledochoduodenostomy
as an optional treatment for complex choledocholithiasis Cir 2014, 81, pp.111-116
5 Choi T.K et al Current management of
intrahepatic stones World J Surg 1990, 14, pp.487-491
6 Guru Trikudanathan, Mustafa A Arain
Advances in the endoscopic management
of common bile duct stones Nature Reviews Gastroenterology & Hepatology 2014, pp.535-544
7 Hyung Jun Kwon, Sang Geol Kim
Surgical treatment for intrahepatic duct stones Korean Journal of Pancreas and Biliary Tract 2012, 17 (2), pp.19-27
8 Xiaoming Ye, Kaiyuan Ni, Xiaoshuai Zhou Laparoscopic versus open left
hemihepatectomy for hepatolithiasis JSR Journal Surgical Research 2015, Volume
199, Issue 2, pp.402-406
9 Yoong Ki Kim, Ho Seung Han, Yoo Seok Yoon, Jai Young Cho Laparoscopic
approach for right-sided intrahepatic duct stones: A comparative study of laparoscopic versus open treatment World Journal of Surgery
2015, Volume 39, Issue 5, pp.1224-1230