Utilization of Laparoscopic Choledochoscopy During Bile Duct Exploration and Evaluation of the Wiper Blade Maneuver for Transcystic Intrahepatic Access

Abstract

Objective: This study aims to examine the indications, techniques, and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the wiper blade maneuver (WBM) for transcystic intrahepatic choledochoscopy. Summary of Background Data: Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particularly with the increasing role of transcystic exploration. Methods: The indications, techniques, and operative and postoperative data on choledochoscopy collected prospectively during transcystic and choledo-chotomy explorations were analyzed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochoscopes. Results: Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during 1320 bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilized more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts, and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. Twenty retained stones (2.1%) were encountered but no choledochoscopy related complications. Conclusions: Choledochoscopy should always be performed during a chol-edochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilized in over 50% of explorations, increasing their rate of success. When attempted, the transcystic WBM achieves intrahepatic access in 70%-80%. It should be part of the training curriculum.

Response to the Comment on “Conventional Surgical Management of Bile Duct Stones: A Service Model and Outcomes of 1318 Laparoscopic Explorations”

“…Our fragmentation techniques depend on whether stone impaction is encountered within the extra or intrahepatic ducts 3 . Repeated manipulations with baskets together with limited stone fracture or balloon catheter dislodgement succeeded in 25% of the current number of 130 impacted stones, balloon dislodgement in 9%, using the choledochoscope to push ampullary stones into the duodenum or from the intramural CD to the CBD to facilitate engaging them in 5% and open conversion in 5% early in the series (choledochoduodenostomy in 3 cases due to failed disimpaction and fragmentation with biopsy forceps in 3) 4 .…”

“…In our view this may suggest that TCE lithotripsy is attempted too often when it should have been possible to determine from the intraoperative cholangiography whether a choledochotomy is a better approach. This would avoid the logistic and clinical complications of lithotripsy, particularly that a significant minority of patients will have an anatomical cystic duct/common hepatic duct junction configuration which is totally incompatible with TCE or with performing the Wiper Blade Maneuvre 3 …”

Multi‐institutional expert update on the use of laparoscopic bile duct exploration in the management of choledocholithiasis: Lesson learned from 3950 procedures

“…In recent years, the use of levering access technology and enhanced surgical techniques (LATEST) 17 have allowed increased rates of transcystic approach in up to 90% of cases. In the present study, the most experienced centers not surprisingly favored the transcystic approach, using advanced methods to improve transcystic exploration such as ultrathin scopes, the use of lithotripsy, and enhanced surgical techniques including the Wiper Blade Manoeuvre for transcystic proximal choledochoscopic access, 18 although a majority of centers preferred the transcholedochal approach.…”

“…Lab‐based hands‐on training on well‐designed models, should be done with training boxes such as the FLS ® (fundamentals of laparoscopic surgery VTI Medical) or pelvitrainers. Many models are available 18 including the PARA model (Porcine Aorto‐Renal Artery that allows a realistic choledochotomy and training in the transcystic access including lithotripsy) 30 . Some follow‐up mentoring with an expert center is necessary and can even be delivered remotely using smart surgery glasses and digital remote assistance platforms.…”

Feasibility and safety of choledochotomy primary closure in laparoscopic common bile duct exploration without biliary drainage: a retrospective study

“…Its success rate varies greatly among different reports and is influenced by various factors, such as stone diameter, location and angle of the cystic duct entering the CBD. At the same time, TCDE may still require partial incision of the CBD or dilation of the cystic duct, which may lead to cystic duct rupture, laceration or avulsion and may require more special equipment, such as a 3 mm choledochoscope 28 . Therefore, we did not perform TCDE in these patients in our study.…”