The secondary CBDS may cause many clinical symptoms and signs, including abdominal pain, obstructive jaundice, cholangitis, and biliary pancreatitis, etc . just like patients in this article, there were as many as 52 patients diagnosed with obstructive jaundice. The ideal management of secondary CBDS with gallstones remains a matter of debate . Since Endoscopy and laparoscopy were introduced into clinic, the conventional approach to the removal of CBDS is usually by pre-, intra or postoperative ERCP followed by LC [2, 5]. ERCP-related complications such as pancreatitis, bleeding and perforation are the main concerns. In addition, Structure and function of Oddi’s sphincter are inevitable, and recurrent retrograde infection of CBD also happen often. Furthermore, ERCP have relatively strict prerequisite for stone removal and a low success rate (about 80%) . For example, the smaller size of the stone, the lower position of the stone closing to the duodenal papilla, etc.
Laparoscopic choledochotomy followed by exploration and stone extraction with choledochoscope has therefore gained popularity for patients with choledocholithiasis and cholelithiasis. In this case, the problems related to T-tube placement, such as patient discomfort, biliary peritonitis, T-tube displacement, etc., have become new problems troubling surgeons [15–16]. In view of this, some surgeons tried to make full use of the natural cystic duct with micro-incision of CBD or confluence so as to facilitate choledochoscope insertion, exploration and removal of CBDS, and micro-incision was closed primarily at the end of operation [13–14]. Inspired by this, we further speculate: could we use the natural orifice comprising of cystic duct and its confluence at the CBD to achieve CBD exploration and stones extraction without incision? Therefore, we designed the current modified methods LD-CBDE, which was laparoscopic transcystic approach for CBD exploration and stones extraction with the dilatation of the confluence. The current design does not require incising the confluence, and primary suture of the mucous and seromuscular layers separately. The dilatation of the confluence not only overcomes the problems that the cystic duct is thin and the spiral valve acts as a barrier in exploration but also dilatates the entrance diameter of the CBD to the inner diameter of largest stone; this makes the insertion of the choledochoscope and stones extraction easier. CBD blood supply is not affected by incision, which can completely avoid postoperative CBD stenosis. The operation was very successful with a success rate of 91.2% (in fact, the success rate can reach 100% in the selective patient) and had a CBDS clearance rate of 100%, and on postoperative follow-up no problems related to a retained stone were encountered.
The reported overall success rates was 88.1% in meta-analysis of eleven randomized trials for LCBDE . It appears that the success rate of 91.2% with present method coincides with those reported in the literature. Using a slightly different surgical approach with a micro-incision at the confluence, Chen et al. and Niu et al reported a success rate of 100% [13–14]. The main reasons for the failure is associated with anatomical problems in our series (6 patients), which suggests the importance of a carefully selected surgical strategy during operation. During the operation, special attention should be paid to the following aspects: Firstly, it is especially important to maintain the cystic duct intact, so as to facilitate the incision, dilatation, insertion of choledochoscope, observation, stones extraction and primary closure. Secondly, it is necessary to correctly identify the confluence and avoid its damage. Finally, limiting factors of success with LTD-CBDE include anatomic features related to the cystic duct and confluence, such as fibrosis and anatomical abnormality of the Calot’s triangle, small size or atresia, tortuous duct, and low level of or posterior insertion of the cystic duct on the CBD, etc. The mean operating time 105 min (ranging from 90 to 120 min) in our series was similar to the results reported by Chen et al.  and Niu et al.Using micro-incision of confluence. They reported mean operating times varied between 104 to 150min. The current operating time is relatively short compared to most LCBDE modality (average 119~194min) [2, 17, 18]. However, we don’t think it is reasonable to directly compare the operation time, because any new modality is technically difficult with a clear learning curve and requires instruments and instruments, and prolongs the operation time. In the future, with technical improvement and more effective logistic organization, the operation time will be further reduced. We thought that this method appears to be a cost-effective method for treating CBDS, although it requires clinical experience as well as advanced laparoscopic skills.
Patients in our study were discharged after a mean postoperative hospital stay of 5.9 days. The hospital stay was significantly shortened compared with 194 patients adopting CBD mini-incision (mean 8 days) reported by Chen et al, however, similar to the hospital stay time of some LCBDE procedures [5, 17, 18]. No mortality was reported in our series, which is in accordance with the findings of other series with other surgical modality [13–14]. 43 cases were followed up one year after LTD-CBDE operation (25 patients lost to follow up); none of our patients presented with evidence of retained or recurrent CBDS and stenosis of CBD.
Our modified LTD-CBDE is safe and effective for the treatment of secondary choledocholithiasis, but a carefully selected surgical strategy during operation should be especially emphasized as suggested by Gigot at al . For patients with anatomical abnormalities, intraperitoneal adhesions in the surgical site just as six patients in our series, the traditional open operation or laparoscopic choledochotomy should be considered as soon as possible in these cases. In addition, despite careful suturing of the confluence with stump wall, there are still 3 cases of postoperative bile leakage. This is not higher than the incidence of LCBDE (5.6% with experienced surgeons vs 17.1% with inexperienced surgeons) reported by liu et al. . As analyzed by liu at al. , it is clear that postoperative bile leakage (and the like) can be reduced with gaining of experience in the technique . Thirdly, in our series, the separation forceps, rather than the balloon, were used in most patients. It is undeniable that the former facilitates a quantitative description of the degree of expansion and resultant better safety. However, Yunnan is a poor province in China, and patients cannot afford the expensive balloon. Therefore, we chose the separation forceps rather than the balloon to dilatate the confluence. This is the biggest shortcoming of the current work, and fortunately, the vast majority of patients who used the separation forceps to dilatate confluence have achieved successfully surgery with LTD-CBDE technique. Finally, although we hypothesized that LTD-CBDE has the potential to reduce postoperative bile duct stricture, this is currently not confirmed and further research is needed. The optimal management of CBDS is dependent on the skills and techniques of the surgical team available at the local hospital. In any case, minimally invasive or non-invasive tissue and/or organ should be the direction of our efforts.