Nghiên cứu ứng dụng phẫu thuật nội soi kết hợp nội soi đường mật điều trị sỏi đường mật tt tiếng anh

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF NATIONAL DEFENSE

108 INSTITUTE OF CLINICAL MEDICAL
ANDPHARMACEUTICAL SCIENCES

VU DUC THU

THE S TUDY IN APPLICATION OF LAPAROS COPIC
COMON BILE DUCT EXPLORATION COMBINED
WITH CHOLANGIOS COPY FOR TREATMENT OF
BILIARY S TONE

Spe ciality: Digestive Surgery
Code : 62720125

SUMMARY OF MEDICAL DOC TORAL THESIS

HA NOI – 2020


T HE THESIS WAS DONE AT 108 INSTITUT E OF CLINICAL
MEDICAL AND PHARMACEUT ICAL SCIENCES

Scientific instructors:
1. Prof.PhD. Nguyen Ngoc Bich
2. Assoc.Prof. PhD. Nguyen Anh Tuan

Reviewer 1:
Reviewer 2:
Reviewer 2:

This thesis will be presented at Institute Council at: 108
institute of clinical medical and pharmaceutical sciences
Day

M onth

Year

The thesis can be found at:
1. National library
2. Library of 108 Institute of clinical medical pharmacological
sciences


1
INTRO DUCTIO N
Biliary stone is a common diseaseall over the world. In Vietnam,
biliary stone is formed locally due to mechanisms of infection of
bacteria and parasite. Consequently,stone is located everywhere on t he
bile ducts, the proportion ofhepatolithiasisis ratherhigh, so it is very
difficult to management.
In 1991, Stoker was the firstsuccessfully performed laparoscopic
common bile duct exploration. This treatment has takenmany
advantages over open surgery such as less pain, quick recovery, small
incisions, fewer complications, ... so it is being widely applied in
treatment of biliary stone in the world.
In Vietnam, laparoscopic common bile duct exploration is still
mainly indicated for choledocholithiasis. Those who have previous
abdominal surgery, urgent surgery, elderly patients,...have been proven
effective to be good results in the world but being not enough

knowledges or still little studied. T echnically, at medical facilities in
Vietnam, surgeons and surgical equipments are very differentfrom:
trocar insertion, path to remove stone, means to extract stone and bile
duct reconstruction, etc.
In addition, the results of studyinglaparoscopic comon bile duct
exploration combined to cholangioscopy for biliary stone are
incomplete or differences between the studies in terms of success rate,
stone clearance, intraoperative injury and complications,...
In order to clarify t he role oflaparoscopic laparoscopic comon
bile duct explorationcombined to cholangioscopy for treatment biliary
stone in Vietnam such as: What about the indicat ions?, How about the
surgical techniques andthe result of treatment? T he thesis titled
“Research onapplication of laparoscopic comon bile duct exploration
combined with cholangioscopy for management of biliary stones”has
been conducted with the two objectives as follows:
1. Studying indications and techniques oflaparoscopic comon bile duct
exploration combined with cholangioscopy for treatment of biliary
stones
2. Evaluating the early results of laparoscopic comon bile duct
explorationcombined with cholangioscopy for treatment of biliary
stones


2
ABO UT TH E TH ESIS
Ne w contributions of the thesis
The author's research results have made new contributions to the
development of the speciality which has scientific significance and high
reliability as follows:
- Re garding indications:

Laparoscopic common bile duct explarion combined with
cholangioscopy
is the
most
commonly
prescribed for
choledocholithiasis with percentage of 73.9%. The elective surgery was
majority, accounting for 89.2%.
Indicat ion after the removal of choledocholithiasis via
endoscopic retrograde cholangiopancreatography failure was 11.7%.
The patients with previous abdominal surgery was 36.9%, of
which biliary surgery was 16.2%.
The proportion of elderly patients is up to 38.7%.
- Re garding te chniques:
Percentage of operation performing through 4 trocars was the
most common with 75.7%.
Performing operation because of adhesiolysis was 40.2% of
cases, of which 100% of cases with a history of biliary tract surgery
need to adhesive surgery.
Transcholedochal approach was common way t o remove stones
which accounted for 90.7%.
Means for extracting stones by basket was the highest rate,
accounting for 43.9%. Other means: Mirizzi was 16.8%, electrohydraulic
lithotripsy was 27.1% and combination of means was 8.4%.
Electrohydraulic lithotripsy was carried on 32.7% of cases.
Reasons for lithotripsy: big stones accounted for 31.4%, incarcereted
and cast-shaped stones were 68.6%.
Kehr drainage was the most populary, accounting for 83.2%;
primary closure was 7.5%, and ligating the remnant cystic duct was 9.3%.
- Re garding early results

The success rate of the operation was 96.4%.
The complete stone clearance rate was 74.8%. The rate stone
clearance separately by each group: choledocholithiasis was 100%,
synchronous choledocholithiasis and hepatolithiasis was 35.7%, the
lowest is hepatolithiasis 10%.


3
The mean operating time was 133.6 ± 46.3 minutes.
The mean postoperative hospital stay was 5.9 ± 2.6 days.
General complications was 10.3%: bile leak 2.8%, int raabdominal abscess 0.9%, pneumonia 6.6%.
Classification of results: good 64.0%, average 34.2% and poor 1.8%.
The thesis structure
The thesis has the structure of 119 pages, in which,
Introduction of 2 pages, Lit erature overview of 38 pages, Research
subject s and methods of 19 pages, Research results of 20 pages,
Discussion of 37 pages, Conclusion of 2 pages and Recommendations
of 1 page.
The thesis consists of 32 tables, 15 photos and 6 charts.
The thesis has 126 references, including: 24 ones in
Vietnamese, 102 ones in English.
Chapte r 1
LITERA TUR E O VERVIEW
1.3.5. Laparoscopic common bile duct e xploration for tre atment of
biliary stone s
In 1991 in Australia, Stoker firstperformed laparoscopic common
bile
duct
exploration
for

5
patients
have
synchronouslycholedocholithiasis and gallblader stone. Subsequently,
many authors from around the world presentedlaparoscopic common
bile duct exploration for choledocholithiasis.
In Vietnam, in 2000, Nguyen Dinh Song Huy
reportedlaparoscopic common bile duct exploration for 25 cases have
extrahepatolithiasis combined to gallblader stone. T he author did not
fill in peritoneal cavity with gas but uses Hashimoto's abdominal lift
system and removestone with Mirizzi, closure the choledochotomy by
open needle holder,...
1.3.5.3. Advantages and disadvantages
Advantages: This is minimally invasive surgery so patients recover
fast er, less pain, reduce hospital stay, low costs. Blood lost in operation
is less. Because of keeping the Oddi sphincter intact, so that it reduce
retrograde infections after surgery. In particularly, removing stone via
transcystic laparoscopic bile ductexplorationis the least invasive
method, keeping the common bile ductintact and fewer wound
infection.


4
Disadvantages: This methodhave to equips with more surgical
facilities and surgeon requires high surgical skills so it is often carried
on in large surgical centers. Infact that, it canface by many difficulties
toperform inhepatolithiasis, previous biliary surgery, urgent situation,
cases of contraindications to inflation of peritoneal cavity.
1.4. Studying indications and te chniques for laparoscopiccommon
bile duct e xploration combine d to cholangioscopy for treatment of

biliary stone
1.4.1. Indications
1.4.1.1. In the world
Stone location: In developed countries, stone is almost located
in common bile duct, sohepatolithiasis is rarely seen. Therefore,studies
did not mentionto laparoscopic common bile duct exploration for
hepatolithiasis. In Southeast Asian countries, more than a decade ago,
laparoscopic common bile duct exploration for hepatolithiasis has been
applied and published research results. Hepatolithiasis biliary stenosis
is a matter of great concern t o authors when making indications, often
contraindicated.
Timing of surgery: Laparoscopic common bile duct exploration
for biliary stone is almost exclusively indicated for selective patients.
Most of the studies are conducted on schedulepatients, recently some
have reported for emergency operations.
After
failed
endoscopic
re trograde
cholangiopancreatography: Intervention to remove stone by
endoscopic retrograde cholangiopancreas is not always successful, the
failure rate is 4-10%. Bansal has an study to compare laparoscopic
common bile duct exploration after failed endoscopic retrograde
cholangiopancreatographyand the group appointed from the outset. T he
success rat e of two groups were equal.
Patients with recurrent hepatolithiasis:in 2008, Chiappetta
firsr performed laparoscopic common bile duct exploration for patients
with recurrent hepatolithiasis. It was safe, highstone clearance. Pu
conducteda comparative study between conventional surgery and
laparoscopic comon bile duct exploration on patients with recurrent

hepatolithiasis. The results of two methods have the same stone
clearance rate, but the laterhave had fewer intraoperative injuries and
complications.


5
1.4.1.2. In Vietnam
In Vietnam, laparoscopic common bile duct exploration
combined with cholangioscopy for treatment of biliary stone has
applied from the late 90s of the twentieth century with indications being
expanded.
In 2006, Nguyen Khac Duc indicated patients with
choledocholithiasis, recurrent biliary stone, urgent surgery, and after failed
endoscopic retrograde cholangiopancreatography.
In 2007, Nguyen Hoang Bac have expanded indications of
laparoscopic comon bile duct exploration for patients with
hepatolithiasis, hepatecomy due t o stone,... However, the author did not
point for emergent surgery.
1.4.2. Te chniques
1.4.2.1. In the world
So far, laparoscopic common bile exploration has been carried
out through two ways: transcholedochal and transcysticapproach.
T echnical steps to extract transcystic approach include: dissect ion of
the cystic duct for recognizing the confluence of the cystic duct withthe
common bile duct,longitudinal incision ismade on t he anterior wall of
the cystic duct and then insertion of a choledochoscope into the
common bile ductto eliminatestone.Technical stepstransductal approach
includes:make a choledochotomy on the long axis of the common bile
duct, then insert the choledochoscope through choledochotomy to
eliminatestone. According to Paganini (2007): elimination stone via

transcystic approach when the stone size is less than 7 mm and locating
below the bifurcat ion of cystic duct and common bile duct.
Transcholedochalapproach when the stone is over 7 mm in size and the
number of stones is more than 5. According to Yoon (2007) and Eric
Lai (2010), the steps of laparoscopic common bile duct exploration for
eliminating hepatolithiasis is similar to choledocholithiasis. All cases of
retained stones or suspicous stones are placed Kehr drain.
1.4.2.2. In Vietnam
In Vietnam, laparoscopic common bile duct exploration
combined with cholangioscopy was applied later and there were some
differences compared with t he authors in the world. In 2000, Nguyen
Dinh Song Huy, performed laparoscopic by Hashimoto abdominal lift
technique. Removing stones from common bile duct with Mirizzi,
closurecholedochotomy with open needle holder. Technique of Nguyen


6
Khac Duc: placed5 trocar: umbilical port, epigastrium (below xiphoid
proccess), left uppper quadrant, right uppper quadrant. Intraoperative
Cholangiography was performed for 79 (70.1%) cases. Intraoperative
cholangioscopy underwent was very limited: 9 cases. Nguyen Hoang
Bac (2007) performed stone extraction via both transcystic and
transcholedochal approach, intraoperative cholangioscopy in 99.4% of
cases, electrohydraulic lithotripsy in 25.5% of cases.
1.5. Studying the early results of laparoscopic common bile duct
exploration combined with cholangioscopy for treatment of biliary
stone
1.5.1. In the world
In developed countries, laparoscopic transcystic common bile
duct exploration is very popular. According to Berthou (2007): T he

success rat e of this method was 75.2%, andlaparoscopic
transcholedochal common bile duct exploration was 97.0%. T he rate of
retained stone was 2.8%, complication 7.9%, mortality 1%. Zhu's study
had laparoscopic comon bile duct exploration to remove hepatolithiasis.
The success rate was 83.33%, operating time was 297.7 ± 85.0 minutes.
Intraoperative stone clearance rate was 66.7%. T he hospital stay was
15.0 ± 5.3 days.
1.5.2. In Vietnam
In 2006, laparoscopic common bile duct exploration for
choledocholithiasis of Nguyen Khac Duc showed that: the rate of
conversion to open surgery was 14.6%, operating time 150 ± 37
minutes. Intraoperative injury 2.75%, retained stone rate 10.25%,
hospital stay 9.9 ± 3.3 days. Complications 3.91%, 2 caseshad to
reoperated.
According to Nguyen Hoang Bac (2007), the success rat e of
laparoscopic common bile duct explorationwas 97.67%. Intraoperative
stone clearance rate reached 68.45%.
Chapte r 2
RES EARC H SUBJECTS AND METHO DS
2.1. Subje cts
Patients with biliary stone have to perform laparoscopic common
bile duct exploration at Vietnamese-Swedish UongBiHospital and
University Medical Center HCMC from May 1, 2015 to September 30,
2018.


7
2.1.1. Inclusion crite ria
Patients diagnosedbiliary stone by: clinical and imaging and have
to perform laparoscopic common bile duct exploration combine to

intraoperative cholangioscopy.
2.1.2. Exclusion criteria
Patients with laparoscopic comon bile duct exploration through a
trocar hole, with attached stone liver resection.
2.2. Study design
Prospective, longitudinal, descriptive study.
2.2.1. Sample size
The sample size of the study is calculated according to the
formula:

n  Z12 / 2

P  (1  P)
e2

P is the retained stone of laparoscopic common bile duct
exploration. According to statistics ducumented in some studies in
Vietnam, the rate of retained stone ranged from 6.50-10.25%, choosing
p = 0.1, instead of the formula we have n = 96.
2.2.2. Equiqments
Surgical laparoscopic system of Striker or Olympus.
Cholangioscopic system CHF. P20Q and lithotripsy Lithotron EL27compact.
2.2.4. Te chnical proce dure
2.2.4.1. Indications and contraindications
Indications: Patients have choledocholithiasis, hepatothiasis
combined to choledocholithiasis,hepatolithiasis. Diamater of common
bile duct is more than 6 mm.
Contraindications: Patients have biliary stones locate only in
segmental ducts or further, severe biliary strictures and liver atrophy
due to stone. Cirrhosis of Child B or more severe, liver cancer,

cholangioma, liver abscess, history of entero-biliary anastomosis
surgery. ASA ≥ 3, cannot be intubated. Cholangitis garade III according
to the standards of Japanese Associat ion of Hepato-Biliary-Pancreatic
Surgery 2018.
2.2.4.5. The technical ste ps
Ste p 1: Trocar in sertion:four-port access wa s usedstone: port number
1: 10-mm umbilical site for telescope, insufflation and taking out
specimens; Port number 2: 10-mm in the leftt midclavicular line


8
below the costal margin; Port number 3: 5 mm in the right
midclavicular line below the costal margin; Port number 4: 5-mm
working port in the epigastrium near xiphoid. In patient have a previous
upper abdominal surgery anothe 5 mm port need to place in right or left
iliac fossa to help dissecting adhesive.
Ste p 2: Explorating abdomen and re vealing the biliary tract:
observe and evaluate the condition of the liver, gallbladder, common
bile duct, inflammation and adhesive surround of portal hepatic region.
Using a hook make an incision 20 mm longitudinal of peritoneal layer
cover common bile duct or common hepatic duct.
Ste p 3: O pening the biliary tract: make an anterior longitudinal
incision ton common bile duct ength of 10-15 mm. In case performing
transcystic exploration, Calot’s triangle along with cystic duct and the
part of gallbladder beyond Calot’s triangle was dissect ed and then make
an 6 mm incision logitudinal cystic duct.
Ste p 4: Re moving stones: T hrough the bile duct opening according to
the location, the size of the stone the surgeon uses the different t ools
goes into the bile duct to remove the stone from the bile duct.
Ste p 5: Biliary tract re pairment: Cutting gallbladder if indicated. In

the case of transcystic exploration, the remnant of cystic duct is
klippedor looped. if transcholedochal exploration, there are 2 solutions:
placeKehr’s tubedrain or primary closure choledochotomy.
Step 6: Ending the surgery: Irrigation the surgical area, remove gauze,
specimens. Place drainage below t he liver, closure the trocar’s wound.
2.2.4.6. Postope rative management
- Postoperative treatment: antibiotics, analgesic and parenteral nutrition
- Evaluation of residual stone: based on ultrasound, cholangiography via
Kehr drain. Patients with retained stone are re-examined after 1 month
and remove stone through the Kehr’s tube t unnel.
2.3. Accessment standards
2.3.1. Gene ral characteristics:
Age, gender, occupat ion and geography. Clinical symptoms:
right lower quadrant pain, fever, jaundice. Combined medical diseases:
cardiovascular, respiratory, diabetes and other diseases. Hematology
and biochemistry.
2. 2.3.2. Indications and techniques oflaparoscopic comon bile duct
exploration combined with cholangioscopy for tre atment of
biliary stone s


9
Stone location, timing operation, history of abdominal surgery,
preoperative intervention. Trocar insertion, the approach exploration,
type of making incision on common bile duct. Means for
extractingstone, the location to perform electrohydraulic lithotripsy ,
lithotripsy reasons, biliary tract repairment, intraoperative injury.
2.3.3. Early results of laparoscopic comon bile duct exploration
combined with cholangioscopy for treatment of biliary stones
The rate of successful surgery. T he lession of liver, gallbladder,

common bile duct, adhesion, stone clearance rate, location of
residualstone. operation time, durat ion of antibiot ics, postoperative pain
level, complications, hospital stay, sorting results.
2.4. Data processing
Using SPSS 20.0 software to analyze data.
2.5. Research e thics
The project has been accepted by108 Institute of Clinical
Medical and Pharmaceutical Sciences for implementation under the
Decision No.287/QD-V108 dated September 10, 2015.


10
2.6. Research chart
The patient diagnosed with bili ary tract stones
(Clinical, ultrasound and / or CT, MRI)

Indication oflaparoscopic surgery combined with
cholangioscopy

Laparoscopic surgery combined with
cholangioscopysuccessfully

General characteristics

Convert to open surgery

Technical description

Result evalu ation

Conclu sion 1

Conclu sion 2


11
Chapte r 3
RES EARC H RESULTS
From May 2015 to September 2018, 111 cases were enrolled to
the study. Vietnam-Swedish UongBi Hospit al had 34 cases, and
University Medical Center HCMC had 77 cases.
3.1. Gene ral characte ristics
3.1.1. Age and gender.
Age:mean 55.3 ± 16.3, ranged from 12 to 93, the age of 50-60 were
commonest 24 (21.6%) cases. Patients under 40 year old have fewer
cases than patients over 60.
Ge nder: women had 72 (64.9%), men were 39 (35.1) cases.
3.2. Indications and te chniques of laparoscopic common bile duct
exploration combined with cholangioscopy for treatment of biliary
stone
3.2.1. Indications
3.2.1.1. Location of stone
Table 3.7. Location of stone
Numbe r of patients
Location
Rate %
(n)
73,9
Choledocholithiasis
82

12,6
Hepatolithiasis
14
15
13,5
51
46,0
Gallbla dder stone
Comm ents:The rate of patients with choledocholithiasis was highest,
accounted 82 (73.9%) cases. Patietns with hepatolithiasis was 26.1%.
3.2.1.2. Timing of surgery
The selected operation had a rat e of 99 (89.2%) cases, the rest
was emergency surgery.
3.2.1.3. Surgical inte rvention before surgery
Interventions to remove stone through endoscopic retrograde
cholangiopancreas had 13 (11.7%) cases.
Choledocholithiasis +hepatolithiasis


12
3.2.1.4. History of abdominal surgery
Table 3.8. History of abdominal surgery
His tory of abdominal surgery
n
Rate %
Cholecystectomy
5
4,5
Conventional common bile duct exploration
18

16,2
Appendectomy
3
2,7
Caesarean
11
9,9
Partial gastrectomy and repair of duodenal ulcer
3
2,7
perforation
Colonectomy
1
0,9
Total
41
36,9
Comm ents:The most common history of biliary tract surgery was 18
open cases and 5 cases of cholecystectomy totaling 20.7%.
3.2.1.5. Elderly patients:The proportion of elderly was 38.7%.
3.2.2. The techniques of laparoscopic common bile duct exploration
combined with cholangioscopy for treatment of biliary stone
There were 4 cases have converted to opened surgery, from here
we will analyze techniques and early surgical results in 107 cases.
3.2.2.1. Numbe r of trocar
Table 3. 9.Numbe r of trocar
Numbe r
3 trocars
4 trocars
5 trocars

6 trocars
Total

n
8
81
11
7
107

Rate %
7,5
75,7
10,3
6,5
100

Comm ents:Surgery using 4 trocar has the highest rate of 75.7%.


13
3.2.2.2. Adhesion and reave aling common bile duct
Table 3.10. Pe rforming adhesiolyosis to re ve al common bile duct
His tory of surgery
Non history of abdominal surgery
Opened common bile duct exploration
Cholecystectomy
Partial gastrectomy and repair of duodenal ulcer
perforation
Ceasarean

Appendectomy
Total

n
16
18
5

Rate %
14,4
16,2
4,5

2

1,8

1
1
43

0,9
0,9
40,2

Comm ents:All patients with previous biliary surgery need to to perform
adhesiolysis to reveal the common bile duct.
3.2.2.3. Approach to e xtract stone
Extractingstonetranscholedochal approach had 89,7% and
transcystic approach 10,3%. There was a case in transcystic approach

group have to be converted to opened surgery.
3.2.2.5. Me ans of extracting stone
Table 3.11. Means of extracting stone
Means of extracting stone
n
Rate %
Flushing
3
2,8
Mirizzi
18
16,8
Basket
47
43,9
Electrohydraulic Lithotripsy
29
27,1
Combining 2 means or more
9
8,4
Cholangioscopy only
1
0,9
Total
107
100
In 9 cases of removing stone by combining means there were 5 cases
have performed electrohydraulic lithotripsy.
Comm ents:The basket was the commonest means to removing stone

43.9%.


14
3.2.2.6. Cholangioscopyand electrohydraulic lithotripsy
Table 3.12. Lesions observed by cholangioscopy
Lesions
n
Rate %
Stone
99
92,5
Stone + ascaris lumbricoides
3
2,8
Stone lived in a biliary sac
1
0,9
Cholangitis
28
26,2
Biliary Stenosis
6
5,6
There were 4 cases, stones were extracted fulfilled immediately by
Mirizzi, so there was no stone when performed cholangioscopy.
Comm ents:The cholangioscopy found stones up to 92.5%.
Table 3.13. Placement of ele ctrohydraulic lithotripsy
Placement of electrohydraulic
N

Rate %
lithotripsy
Common bile duct
13
37,1
Oddi
5
14,3
Left hepatic duct
2
5,7
Right hepatic duct
10
28,6
Left and right hepatic duct
4
11,4
Se gmental and subsegmetal duct
1
2,9
Total
35
100
Comm ents:Electrohydraulic lithotripsy for stones locating in common
bile duct were commnest 13 (37.1%).
The reason of lithotripsy: big stone 24 cases, incarcerated and castshaped stones 11 cases.
3.2.2.7. Biliary tract re pairment
Table 3.14. Type of biliary tract re pairment
Type of re pairment
n

Rate %
Clipping remnant cystic duct
10
9,3
Placing Kehr
89
83,2
Primary closure common bile duct
8
7,5
Common bile duct
Running suture
64
66,0
closure type
Interrupted suture
33
34,0
There were 51 cases of cholecystectomy due to gallbladder stone.
Comm ents:placing Kehr applies up to 89 (83.2%) cases.


15
3.2.2.8. Intraope rative injury
There was a case having perforation of the duodenum when
dissection and immidiately repaired by laparoscopic suture.
3.3. Early re sults of laparoscopic common bile duct exploration
combined with cholangioscopy for treatmnet biliary stone
3.3.1. Success rate
Research had performed successf ullaparoscopic comon bile

duct exploration for 107 cases. T here were 4 (3.6%) cases have to
convert to open surgery due t o the following reasons: one patient could
not dissect ed to approach to portal hepatic region. T wo patients could
be approach t o the portal hepatic region but did not find the common
bile duct. Of them, all have hadprevious common bile duct exploration
before. A patient with Oddistricture had to make a small incision in the
right uppper quadrant to bilico-entero anastomosis.
3.3.3. Stone clearance
Table 3.19. Stone clearance rate by location
Location of stone
Choledocholithiasis (n = 69)
Hepatolithiasis(n = 10)
Choledocholithiasis combined to hepatolithiasis(n
= 28)
General (n = 107)

n
69
1

Rate %
100
10,0

10

35,7

80

74,8

Comm ents:the rate of intraoperative stone clearance in patients with
choledocholithiasiswas up t o 100%.
Table 3.20. Location of re sidual stone
Location of stone
Left hepatic duct and further
Righthepatic duct and further
T wo of hepatic duct and further
Common bile duct and right hepatic duct
Se gmental duct
Total

n
4
9
11
1
2
27

Rate %
3,7
8,4
10,3
0,9
1,9
25,2

Comm ents:Most residual stone was located intrahepatobiliary tract .

16
Table 3.22. Re sidual stone afte r extracting viaKehr tunnel
Location of stone
Left hepatic tract
Right hepatic tract
Left hepatic biliary tract + Right hepatic tract
Common bile duct
Total

n
2
1
7
0
10

Rate %
1,9
0,9
6,5
0,0
9,3

Comm ents:all residual stone was locat ed intrahepatobiliary tract.
Table 3.23. Final stone extracting result
Stone location
n
Rate %

Choledocholithiasis (n = 69)
69
100
Hepatolithiasis (n = 10)
4
40,0
Choledocholithiasis combined to
24
85,7
hepatolithiasis(n = 28)
General (n = 107)
97
90,7
Comm ents:The rate of stone clearance had only reached to 40% for
hepatolithiasis, but 100% for choledocholithiasis.
3.3.4. Ope ration duration
Table 3.24. O pe ration duration
Duration
n
Rate %
Average
Longest Shortest
(minute)
45-60
2
1,9
>60-90
19
17,8
>90-120

29
27,1
>120-150
29
27,1
133,6 ±46,3
60
300
>150-180
17
15,9
> 180
11
10,3
Total
107
100
Comments:The operation time ranged from 90 to 150 minutes was the most
common 54.2%.


17
3.3.6. Duration of hospitalization
The average duration of hospitalization is 5.9 ± 2.6 days, the
shortest is 2 days, the longest is 21 days. T he average time for bowel
movements is 36.8 hours, the shortest is 16 hours and the longest is 72
hours. Kehr draining time averages 28.8 days, t he shortest is 11 days,
the longest is 60 days.
3.3.7. Complications
Table 3.28. Classification of complications

Complications
n
Pneumonia
7
Wound infection + bile leak
1
Bile leak
2
Intra-abdominal infection
1
Total
11
Comm ents:Pneumonia has had the highest rate of 6.5%.
3.3.8. Gene ral results
Table 3.29. Final re sults
Type
n
Good
71
Moderate
34
Poor
2
Bad
0
Total
107

Rate %
6,5

0,9
1,9
0,9
10,3

Rate %
66,4
31,8
1,8
0
100

Comm ents:The surgery achieved good results up to 66.4%, only 2
(1.8%) cases achieved poor results, no deaths.
Chapte r 4
DISCUSSIO N
4.1. Gene ral characte ristics
4.1.1. Age and gender
Biliary stone disease can occur at any age. The average age of
patients in the study was 55.3 ± 16.3, the highest was 93, the lowest
was 12, the group of working-age population (30-60 years) accounted


18
to 57.7%. In Vietnam, the average age of patients in previous studies
was from 41.8 to 46.9 years, of which the proportion of young people is
more. In recent years, the age of biliary stone tends to older than before.
The study results showed that the proportion of female patients
was 64.9%. This ratio is common in domestic and worldwide studies.
So far, no theory has clearly stated why women have stone disease

more than men.
4.2. Indications and te chniques of laparoscopic comom bile duct
exploration combined with cholangioscopy for treatment biliary
stone
4.2.1. Indications
4.2.1.1. Stone location
In developed countries, most studies have focused on laparoscopic
common bile duct exploration for stone, very little mention of
hepatolithiasis. In Vietnam, biliary stone is located both in
extrahepatobiliary and intrahepatobiliary tract so that laparoscopic
comon bile duct exploration is not only indicated for
choledocholithiasis but also applied to hepatolithiasis. When
init ialmaking applications, authors often choose cases of
choledocholithiasi, after that’s they will extend the indicat ion to the
hepatolithiasis. The rate of hepatolithiasis in previous studies was from
5.1% to 33.1%. The study have indication for hepatolithiasis accounted
to 26.12%.
4.2.1.2. Timing of surgery
Scheduled operation is the most common indication. Recently,
there have been reports of emergency laparoscopic comon bile duct
exploration for patients with acute cholangitis due to biliary stone.
However, the indication is limited to non-severe cholangitis. The study
had 99 (89.8%) casesto be performed in schedule, the rest were
emergency operation 12 (10.8%). In our country, the rate of application
of laparoscopic common bile duct exploration in the emergency
situation was about 0 - 3.65%.


19
4.2.1.3. Laparoscopic common bile duct exploration afte r failed

endoscopic stone e xtraction
In developed country, with the advent oflaparoscopic
cholecystectomy, endoscopic retrograde cholangiopancretography has
been very popular. Choledocholithiasis synchronous with gallbladder
stone can be conducted by: laparoscopic cholecystectomy and then
endoscopic retrograde cholangiopancretography to extract stone or
contrary. Endoscopic retrograde cholangiopancreatography extracting
stone has a failure rate of 4 - 10%, in case of failure the patient will
have to convert to other methods to remove stone, in which
laparoscopic common bile duct exploration is one of the first
alterations. In this study, there were 13 unsuccessful cases of failed
endoscopic extracting stone, including: 12 cases could remove stone
and onehave remnant stones. All these cases have successful
performed laparoscopy common bile duct exploration. Here,
laparoscopic common bile duct explorationplay a roll as a preventive
method for endoscopic retrograde cholangiopancretography.
4.2.1.4. Recurrent biliary stone
The study had 41 (36.93%) cases with a history of open abdominal
surgery: common bile duct exploration 18 (16.21%) cases,
cholecystectomy 5 (4.50%) cases. So far, open surgery for cases
withhistory upper abdominal surgery, especially previous biliary
operation is still considered standard method. In Vietnam, patients with
recurrent stonehas been perfomed laparoscopic common bile duct
exploration ranged from 0 - 6.57%. In Pu's study, comparing
laparoscopic comon bile duct explorationto open surgery for recurrent
choledocholithiasis. The results: operation time and stone clearance rate
were equal, but in the open surgery group had more postoperative
complications and longer hospital stay.
4.2.1.5. Elde rly patients
Are laparoscopic common bile duct exploration suitable for the

elderly? is a question that is rarely mentioned by Vietnamese
researchers. The study included 24 (21.6%) cases of people over 70


20
years old, in the age group of 60 and older, there were 43 (38.7%)
cases. T he proportion of the elderly in the study is relatively high
compared to previous studies in the country. In Vietnam, many elderly
patients have had perfomed laparoscopic common bile duct exploration,
but there has not been a separate study for this group. The study of
Nguyen Hoang Bac has 27.9% of cases over 70 years old
undergoinglaparoscopic common bile duct exploration, no deaths after
surgery.
4.2.2.Te chniques
4.2.2. 1. Trocar insertion
The studyused 4 trocar for 81 (75.70%) cases. All of them have first
time performed common bile duct exploration. We want to emphasize the
role of the trocar number 4th. This is the approach for us t o put Mirizzi
or choledoscope into the common bile duct with the shortest distance. It
help to faciltate extracting stone easier. At the end of the surgery, a long
branch of Kehr tube will be taken out of the abdominal wall through
this port. Placing drainage like t hat will create a shortest, non-twisting
tunnel that will allow good int ervention to remove stone if any.
4.2.2.3. Approach to remove stone
In developed countries, laparoscopic common bile duct exploration
is carried on through two approachs: transcystic and transcholedochal
route. Among them, laparoscopic transcystic commonbile duct
exploration
is the first
choice for cases that have

synchronouslycommon bile duct stone and gallbladder stone. This
method can keep intact anatomical structure of the common bile duct.
The main disadvantage of this method that it is impossible to extract
stones live in hepatobiliary. The study have performed laparoscopic
transcystic common bile duct exploratin for 11 cases. There was one
case have to convert to cholochotomy due t o having many stones. T he
characteristics of biliary stone in our country as: big stone, large
numbers, proportion of hepatolithiasis is still so high, so that
laparoscopic transcholedochal common bile duct exploration is more
popular.


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4.2.2.5. Me ans of extracting stone
The rate of using stone extracting devices of the study were:
Mirizzi16.82%, basket 43.93% and electrohydraulic lithotripsy 27.10%.
Among them, Mirizzi is a conventional mean to extract stone.
Advantages of removing stone with Mirizzi as: easy to extract stone
located in common bile duct. In addition, surgeons are used to handling
it in open surgery. Disadvantages of using Mirizzi: rather difficult to
handle its in cases of patients with thick abdominal wall, incarcerated
stone, too large stone, or stones lies far from choledochotomy. The rate
of using basket to remove stone of this study is higher than previous
studies. For stones that are out of reach of Mirizzi, removing stone
bybasket is more effective.
The study performed intraoperative electrohydraulic lithotripsy for
35 (32.7%) cases, including 34 cases performed transcholechotomy,
there was only one case perform transcystic approach. This case had a
big stone that could not take out by basket (Table 3.13). The position
which we performed electrohydraulic lithotripsy with high frequency is

common bile duct (13 cases). There was one case stone lived inbiliary
sac near Oddi that discovered and eliminated by lithotripsy
successfully. The reasons performed electrohydraulic lithotripsy of the
studyas follow: big stone to 31.4%, incarcerated and cast-shaped
68.6%. T he European-American authors mainly performed
electrohydraulic lithotripsy transcystic approach for incarcerated stones
in the common bile duct. The study performed intraoperative
electrohydraulic lithotripsy at all locations on the biliary tract except at
the subsegmental duct level.
4.2.2.7. Biliary tract re pairment
The study had 10 successful cases of removing stonetranscystic
common bile duct exploration.The remnant the cystic duct was clipped
or intracorporal looped. In the choledochotomy group, there were 89
(83.16%) cases to be placedKehr’s t ube. The longbranch of Kehr’s t ube
was carried out through the 4th trocar port. This could facilitate to
removal of remnant stone (if any) through t he Kehr’s t ube t unnel later.


22
In the last 10 - 20 years, many authors advocated primary closure
choledochotomy immediately. In the study have had 8 cases to perform
primary closure choledochotomy. The criteria implementedprimary
closure choledochotomy of the study as follow: stone cleared, diameter
of common bile duct over 8 mm and little inflammation or no edema in the
common bile duct wall.

4.2.2.8. Intraope rative injury
The study showed 1 case of duodenal perforation while dissect ing
dense adhesion of prtal hepatic region. This was laparoscopical repaired
immediately. Postoperatively, there were no leakage. In my knowledge,

postoperative complications has been published in the literature:
bleeding, small int estinal perforation, colon perforation and common
bile duct injury.
4.3. Early re sults of laparoscopic common bile duct e xploarion
combined with cholangioscopic common bile duct e xploration for
tre atment of biliary stone
4.3.1. Success rate
The rate of successful surgery of the study was 96.40%. There
were 4 (3.60%) cases have converted to open surgery. Reasons for open
surgery were: 2 cases, common bile duct could not be found, 1 case was
failed to reach hepatic portal region, 1 case was made an small
incisionsmall incision in the right uppper quadrant in order to perform
bilicoentero anastomosis. In addition, surgeon experiences play an
important role: in the new period of applying this method to treat
choledocholithiasis in Vietnam, the rate of conversion to open surgery
was a bout 11.48 - 15.15%. Reasons for open surgery included: massive
bleeding, biliary injury, incarcerated stone in common bile duct or
Oddi.
4.3.3. Stone clearance rate
Stoneclearance is the central issue of surgery or intervetion in t he
treatment of biliary stone. The stone clearance of laparoscopic common
bile duct exploration combined with cholangioscopy for treatment of
choledocholithiasis may reach to 96.7 - 100%. T he study had a general
intraoperative stone clearance rate of 74.76%. All 69 (100%) cases of


23
choledocholithiasis were cleared immediately during surgery. Thus, this
rate of the study has reached the same level with many recently
published studies. However, the stone clearance rate decreases rapidly

when the stones live in intrahepatobiliary tract. In a study of Nguyen
Hoang Bac, the intraoperative stone clearance rate of a group with
hepatolithiasis was less than 20%. We believe that the high rate of
residual stone in hepatolithiais is the greatest limitation of the study.
4.3.5. Ope rating time
The average operation time of the study was 133.60 ± 46.63
minutes similar to the other authors. The experiences and skills of the
surgeon are important for the length of the surgery. At
VietDucHospital, the initialperiod of applying laparoscopic common
bile duct exploration took average time of surgery was 180 minutes.
4.3.7. Hospital stay
The average hospital stay in the study was: 5.86 ± 2.56 days, this result
is equivalent to the statistics of Nguyen Ngoc Bich. Laparoscopic
common bile duct is the minimally invasive method that can
reducehospital stay and fastpostoperative recovery. The level of
postoperative pain is less, early rehabilitation functions: motive, gas,
feeding,..contribute to reducing durat ion of hospitalization. In
Paganini’s study, the group of patients who had laparoscopic
transcystic common bile duct exploration was equivalent to simple
laparoscopic cholecystectomy.
4.3.8. Complications
The most common complication of laparoscopic common bile duct
exploration was bile leak (7.8%). This complication is the main reason
for reoperation, even death. T he study have had 2 (8.7%)
casesocc ured bile leak. All of them have had low volume leaka ge so
that’s no need to carry on intervention, completely solveby medical
treatment, however it take longer hospit al stay. Wound infect ion was
very rare in laparoscopic common bile duct exploration 0 - 1.97%
which is an outstanding advantage. Pneumonia after surgery wa s the
most common complication of study 6.60%, most occured in patients

over 70 years of age.