|Year : 2014 | Volume
| Issue : 2 | Page : 76-79
Use of rigid tubal ligation scope: Serendipity in laparoscopic common bile duct exploration
Manash Ranjan Sahoo, Anil Kumar Thimmegowda, Syama Sundar Behera
Department of Surgery, S.C.B. Medical College, Cuttack, Odisha, India
|Date of Submission||07-Feb-2013|
|Date of Acceptance||10-Jun-2013|
|Date of Web Publication||7-Apr-2014|
Manash Ranjan Sahoo
S.C.B Medical College, Cuttack, Odisha - 753007
Source of Support: None, Conflict of Interest: None
Aim : To assess the feasibility, safety of rigid tubal ligation scope in laparoscopic common bile duct (CBD) exploration. Materials and Methods: Rigid nephroscope was used for laparoscopic CBD exploration until one day we tried the same with the rigid tubal ligation scope, which was passed easily into CBD both proximally and distally visualising the interior of the duct for presence of stone that were removed using endoscopic retrograde cholangiopancreaticography (ERCP) basket. This serendipity led us to use this scope for numerous patients from then on. A total of 62 patients, including male and female, underwent laparoscopic CBD exploration after choledochotomy with rigid tubal ligation scope between March 2007 and December 2012 followed by cholecystectomy. All the patients had both cholelithiasis and choledocholithiasis with minimum duct diameter of 12 mm. A total of 48 patients were given T-tube through choledochotomy and closed, and the remaining 14 patients had primary closure of choledochotomy. Results: There were no intra-operative complications in any of the patients like CBD injury or portal vein injury. Post-operatively graded clamping of T-tube was done and was removed after 15 days in the patients who were given T-tube. None had retained the stone after T-tube cholangiography, which was done before removing the tube. Mean duration of follow up was 6 months. No patients had any complaints during the follow up. Conclusion: Laparoscopic CBD exploration is also feasible with rigid tubal ligation scope. With experienced surgeons, CBD injury is very minimal and stone clearance can be achieved in almost all patients. This rigid tubal ligation scope can be an alternative to other rigid and flexible scopes.
Keywords: Flexible choledochoscope, laparoscopic CBD exploration, nephroscope, rigid scopes, tubal ligation scope
|How to cite this article:|
Sahoo MR, Thimmegowda AK, Behera SS. Use of rigid tubal ligation scope: Serendipity in laparoscopic common bile duct exploration. J Min Access Surg 2014;10:76-9
|How to cite this URL:|
Sahoo MR, Thimmegowda AK, Behera SS. Use of rigid tubal ligation scope: Serendipity in laparoscopic common bile duct exploration. J Min Access Surg [serial online] 2014 [cited 2019 Dec 10];10:76-9. Available from: http://www.journalofmas.com/text.asp?2014/10/2/76/129956
| ¤ Introduction|| |
In 1991, Petelin et al. first described laparoscopic surgery for common bile duct (CBD) stones. The technique has evolved since then and several studies have concluded that laparoscopic common bile duct exploration (LCBDE) procedures are superior to sequential endolaparoscopic treatment. Cholelithiasis occurs more frequently with advanced age , and is a common disease of the elderly. CBD stones occur in 15-20% of patients with cholelithiasis. Nearly 2-5% of the patients present with residual biliary stones after biliary tract surgery. Only 5.2-12% of cases are asymptomatic. With laparoscopic cholecystectomy (LC) becoming the gold standard for cholelithiasis, the treatment for CBD stone has changed and many options available include (A) transcystic LCBDE, (B) CBD exploration via choledochotomy, (C) Placement of an endobiliary stent, (D) post-operative endoscopic retrograde cholangiopancreatography (ERCP) and intra-operative ERCP and (E) Open CBD exploration. The advent of ERCP with endoscopic sphincterotomy (ES) avoids open CBD exploration reducing their morbidity and mortality.  ERCP also has a lot of complications especially in elderly patients with co-morbidity. LCBDE has all the advantages of minimal access and is also most cost effective compared with the other options. ,, LCBDE is done using flexible choledochoscope or rigid scopes. Most of them use rigid nephroscope, instead of flexible choledochoscope, getting good results since flexible choledoscope is very costly and maintenance is difficult. We were also using the rigid nephroscope for a year. Because of the national family control programme, tubal ligation scope is readily available in almost all centres and is readily and easily accessible. We have both the rigid nephroscope and rigid tubal ligation scope in our department. One day we used the other available scope, the rigid tubal ligation scope, which was passed easily into CBD both proximally and distally visualising the interior of the duct for presence of stones that were removed using ERCP basket. This serendipity led us to use this scope for numerous patients from then on. Hence, we present our experience of LCBDE using the rigid tubal ligation scope.
| ¤ Materials and Methods|| |
A total of 62 patients, 20 male and 42 female, underwent LCBDE after choledochotomy with rigid tubal ligation scope between March 2007 and December 2012 followed by cholecystectomy. All patients had both cholelithiasis and choledocholithiasis with minimum duct diameter of 12 mm. For 22 patients who had pre-operative jaundice, high oral glucose, vitamin k, lactulose syrup, oral ursodeoxycholic acid were given for about a week and then taken for surgery. Intra-operative characteristics like time taken for surgery, CBD injury and injury to vital structures like portal vein, hepatic artery were taken into consideration.
Through a four port approach CBD is addressed first. After choledochotomy the rigid tubal ligation scope is inserted through the umbilical port [Figure 1] to visualise interior of the bile duct proximally till both the right and left hepatic duct interiors are visible [Figure 2], while the regular scope was introduced through epigastric port and manipulation of other instruments was not required. Next the rigid tubal ligation scope was introduced through the epigastric port, which is to the right of falciform ligament distally till ampulla of vater is visible with continuous irrigation while regular scope was introduced in the umbilical port. Any stones, which were found, were basketted out with the ERCP basket passed through the scope [Figure 3]. Then LC was done. While 48 patients were given T-tube through choledochotomy and closed, the remaining 14 patients had primary closure of choledochotomy.
|Figure 1: Rigid tubal ligation scope is inserted through the umbilical port|
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|Figure 3: Stones found were basketted out with ERCP basket passed through the scope|
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Analgesics were given only for a day. All patients were started oral diet on day 2 after surgery. Graded clamping was started on the third day and fully clamped by the fifth day and all the patients were discharged before day 7. They were asked to come after 15 days and removal of the T-tube was done after T-tube cholangiogram. All patients were followed up for a mean of 6 months.
| ¤ Results|| |
There were no intra-operative complications in any of the patients like CBD injury or portal vein injury. Mean operative time was 146 min. Post-operatively patients were on minimal analgesia only for a day or two. Graded clamping of T-tube was done from day 3 and completely clamped by day 5 and patients were discharged within day 7 and the T-tube was removed after 15 days. T-tube cholangiography done before removal of T-tube in patients who had been given T-tube and ERCP done in the third week in patients who had primary closure of choledochotomy showed no retained stones. Mean duration of follow up was 6 months. No patients had any complaints during the follow up.
| ¤ Discussion|| |
There is dispute regarding the optimal treatment for concomitant gallstones and CBD stone. ,, ERCP pre-operatively or post-operatively, prior to LC can be used to manage patients who have suffered from concomitant gallstones and CBD stone in the laparoscopic era. , There are several drawbacks of this approach even though this is effective and safe for removing the CBD stones. They are two hospital admissions, two periods of anaesthesia, increase in length of hospital stay and hospitalisation expenses. If intra-operative cholangiography in LC after successful ERCP shows CBD stones, surgeons will face the dilemma of depending on LCBDE, post-operative ERCP or traditional open choledochotomy. In addition, pre-operative ERCP can produce false-negative results, leading to the possibility of morbidity and mortality. ,,,,, Post-operative ERCP can avoid the risk associated with pre-operative ERCP to patients without CBD stone, but it necessitates another surgical procedure when pre-operative ERCP fails to remove the CBD stone.  Both pre-operative and post-operative ERCP have some short-term and long-term complications. For instance, they may result in post-operative complications, including bleeding, perforation, pancreatitis and even death ,,, and stenosis of the Sphincter of Oddi More Details, cholangitis associated with duodenal content reflux as long-term complications. Tranter and Thompson  reported that the combined morbidity rate ranged from 1% to 19% (median, 13%) for ERCP with endoscopic stenting (ES) followed by LC and from 2% to 17% (median, 8%) for LCBDE. However, we can avoid complications such as pancreatitis, stenosis of the sphincter of Oddi and cholangitis associated with duodenal content reflux in the process of LCBDE because sphincter of Oddi is preserved. ERCP is difficult for removing a large stone, for which choledochoscope or any rigid scope is useful and easier to inspect CBD. Similar studies by Sarkar et al. and Khan et al. have shown that rigid nephroscope is superior to flexible choledochoscope in removing large stones and is cost effective.
LCBDE is a demanding technique with a long learning curve,  which has replaced open CBD exploration. It must be performed with a variety of techniques under laparoscopy, which is a relatively complicated procedure. It has been reported that LCBDE can be performed during a single procedure and is superior to ERCP with LC in terms of patient risk and cost effectiveness. , It is considered to be a safe and efficient treatment for choledocholithiasis; it is associated with a high stone clearance rate ranging from 84% to 97%, a post-operative morbidity rate of 4-16% and a mortality rate of approximately 0-0.8%. ,,,, However, T-tube drainage has been routinely employed after choledochotomy to decompress the bile duct and decrease biliary complications. , The cost of single-stage (LC + LCBDE) management was lower than those for two-stage (LC + ERCP) management.  Also other studies , have shown the same. We performed LCBDE only through the choledochotomy method, for all the cases. Compared with the transcystic approach, choledochotomy approach is a demanding technique with a long learning curve, but multiple stones as well as large stones can be removed more easily, which cannot be done with the transcystic method. Even though time taken for surgery was bit longer at the initial of the learning curve, it can be gradually reduced with experience, which is also true in this study.
Due to limitations of flexible choledochoscope like high cost and unable to retrieve very big stones, many surgeons are using rigid nephroscope with good results. , We were also using the rigid nephroscope for a year. Because of the national family control programme, tubal ligation scope is readily available in almost all centres and is readily and easily accessible. We have both the rigid nephroscope and the rigid tubal ligation scope in our department. One day we used the other available scope, the rigid tubal ligation scope; since then we have been using this scope in many patients achieving the same results as the rigid nephroscope.
| ¤ Conclusion|| |
LCBDE with LC in single stage is cost effective, safe even with the rigid tubal ligation scope with no complications seen in this study with use of the rigid scope. Even though time taken for surgery was bit longer, at the initial stages of the learning curve, it gradually reduced with experience. With experienced surgeons CBD injury is very minimal and stone clearance can be achieved in almost all patients. Because it is easily available, this rigid tubal ligation scope can be an alternative method providing results as good as the flexible choledochoscope or the rigid nephroscope.
| ¤ References|| |
|1.||Ponsky JL, Heniford BT, Gersin K. Choledocholithiasis: Evolving intraoperative strategies. Am Surg 2000;66:262-8. |
|2.||Hungness ES, Soper NJ. Management of common bile duct stones. J Gastrointest Surg 2006;10:612-9. |
|3.||Tranter SE, Thompson MH. Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg 2002;89:1495-504. |
|4.||Petelin J. Laparoscopic approach to common bile duct exploration. Surg Endosc 2003;17:1705-15. |
|5.||Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, et al. E.A.E.S. multicenter prospective randomized trial comparing two stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999;13:952-7. |
|6.||Rhodes M, Susmon L, Cohen L, Lewis MP. Randomized trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 1998;351:159-61. |
|7.||Rogers SJ, Cello JP, Horn JK, Siperstein AE, Schecter WP, Campbell AR, et al. Prospective randomized trial of LC+LCBDE vs ERCP/S+LC for common bile duct stone disease. Arch Surg 2010;145:28-33. |
|8.||Wright BE, Freeman ML, Cumming JK, Quickel RR, Mandal AK. Current management of common bile duct stones: Is there a role for laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography as a single-stage procedure? Surgery 2002;132:729-35. |
|9.||Poulose BK, Speroff T, Holzman MD. Optimizing choledocholithiasis management: A cost-effectiveness analysis. Arch Surg 2007;142:43-8. |
|10.||Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gall bladder and bile duct stones: A combined endoscopic-laparoscopic technique. Int J Surg 2009;7:338-46. |
|11.||Nathanson LK, O'Rourke NA, Martin IJ, Fielding GA, Cowen AE, Roberts RK, et al. Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: A randomized trial. Ann Surg 2005;242:188-92. |
|12.||Wang P, Li ZS, Liu F, Ren X, Lu NH, Fan ZN, et al. Risk factors for ERCP-related complications: A prospective multicenter study. Am J Gastroenterol 2009;104:31-40. |
|13.||Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, et al. Incidence rates of post-ERCP complications: A systematic survey of prospective studies. Am J Gastroenterol 2007;102:1781-8. |
|14.||Suissa A, Yassin K, Lavy A, Lachter J, Chermech I, Karban A, et al. Outcome and early complications of ERCP: A prospective single center study. Hepatogastroenterology 2005;52:352-5. |
|15.||Masci E, Toti G, Mariani A, Curioni S, Lomazzi A, Dinelli M, et al. Complications of diagnostic and therapeutic ERCP: A prospective multicenter study. Am J Gastroenterol 2001;96:417-23. |
|16.||Vecchio R, MacFadyen BV. Laparoscopic common bile duct exploration. Langenbecks Arch Surg 2002;387:45-54. |
|17.||Decker G, Borie F, Millat B, Berthou JC, Deleuze A, Drouard F, et al. One hundred laparoscopic choledochotomies with primary closure of the common bile duct. Surg Endosc 2003;17:12-8. |
|18.||Rojas-Ortega S, Arizpe-Bravo D, Marín López ER, Cesin-Sánchez R, Roman GR, Gómez C, et al. Transcystic common bile duct exploration in the management of patients with choledocholithiasis. J Gastrointest Surg 2003;7:492-6. |
|19.||Thompson MH, Tranter SE. All-comers policy for laparoscopic exploration of the common bile duct. Br J Surg 2002;89:1608-12. |
|20.||Tinoco R, Tinoco A, El-Kadre L, Peres L, Sueth D. Laparoscopic common bile duct exploration. Ann Surg 2008;247:674-9. |
|21.||Williams JA, Treacy PJ, Sidey P, Worthley CS, Townsend NC, Russell EA, et al. Primary duct closure versus T-tube drainage following exploration of the common bile duct. Aust N Z J Surg 1994;64:823-6. |
|22.||Paganini AM, Feliciotti F, Guerrieri M, Tamburini A, De Sanctis A, Campagnacci R, et al. Laparoscopic common bile duct exploration. J Laparoendosc Adv Surg Tech A 2001;11:391-400. |
|23.||Liberman MA, Phillips EH, Carroll BJ, Fallas MJ, Rosenthal R, Hiatt J, et al. Cost-effective management of complicated choledocholithiasis: Laparoscopic transcystic duct exploration or endoscopic sphincterotomy. J Am Coll Surg 1996;182:488-94. |
|24.||Urbach DR, Khajanchee YS, Jobe BA, Standage BA, Hansen PD, Swanstrom LL, et al. Cost-effective management of common bile duct stones: A decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, laparoscopic bile duct exploration. Surg Endosc 2001;15:4-13. |
|25.||Sarkar S, Sadhu S, Jahangir T, Pandit K, Dubey S, Roy MK, et al. Laparoscopic common bile duct exploration using a rigid nephroscope. Br J Surg 2009; 96:412-6. |
|26.||Khan M, Qadri SJ, Nazir SS. Use of rigid nephroscope for laparoscopic common bile duct exploration-a single-center experience World J Surg 2010;34:784-90. |
[Figure 1], [Figure 2], [Figure 3]