Laparoscopic common bile duct exploration 腹腔镜总胆管探查术.PPT

Laparoscopic common bile duct exploration腹腔鏡總膽管探查術 奇美醫學中心　溫義輝 Introduction 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 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. 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 Large / impacted / too many stones in CBD (CHD) s/p exploratory laparotomy Procedures of laparoscopic choledochotomy LC with routine use of IOC Choledochotomy: electrical cauterization (fine needle / low electric diathermy current) Choledocholithotomy: choledochoscopy (EHL) Placement of T-tube: tailored T-tube with split arm Suturing of CBD Transfixing sutures (3-0 plain catgut) Completion cholangiography if indicated Result (I) Result (II) Result (III) Outcome of biliary complication after laparoscopic choledochotomy 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. 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). 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 stan