Published online Apr 7, 2019. doi: 10.3748/wjg.v25.i13.1531
Peer-review started: January 29, 2019
First decision: February 26, 2019
Revised: March 5, 2019
Accepted: March 11, 2019
Article in press: March 12, 2019
Published online: April 7, 2019
Surgeries for benign diseases of the extrahepatic bile duct (EHBD) are classified as lithotomy (i.e., choledocholithotomy) or diversion (i.e., choledochojejunostomy). Because of technical challenges, laparoscopic approaches for these surgeries have not gained worldwide popularity. The right upper quadrant of the abdomen is advantageous for laparoscopic procedures, and laparoscopic choledochojejunostomy is safe and feasible. Herein, we summarize tips and pitfalls in the actual procedures of choledocholithotomy. Laparoscopic choledocholithotomy with primary closure of the transductal incision and transcystic C-tube drainage has excellent clinical outcomes; however, emergent biliary drainage without endoscopic sphincterotomy and preoperative removal of anesthetic risk factors are required. Elastic suture should never be ligated directly on the cystic duct. Interrupted suture placement is the first choice for hemostasis near the EHBD. To prevent progressive laceration of the EHBD, full-layer interrupted sutures are placed at the upper and lower edges of the transductal incision. Cholangioscopy has only two-way operation; using dedicated forceps to atraumatically grasp the cholangioscope is important for smart maneuvering. The duration of intraoperative stone clearance accounts for most of the operative time. Moreover, dedicated forceps are an important instrument for atraumatic grasping of the cholangioscope. Damage to the cholangioscope requires expensive repair. Laparoscopic approach for choledocholithotomy involves technical difficulties. I hope this document with the visual explanation and literature review will be informative for skillful surgeons.
Core tip: The right upper quadrant of the abdomen is advantageous for laparoscopic procedures. Laparoscopic choledocholithotomy is safe and feasible, although this laparoscopic approach involves technical difficulties. Endoscopic sphincterotomy destroys the physiological function of Oddi’s sphincter. Laparoscopic choledocholithotomy has excellent clinical outcomes; however, emergent biliary drainage and removal of anesthetic risk factors are required preoperatively. Cholangiographic removal of stones strongly affects operative time. Cholangioscopy has only two-way operation; using dedicated forceps to atraumatically grasp the cholangioscope is important for smart maneuvering.