A study of primary single and layered suture technique by using two-port laparoscopic choledocholithotomy.

BACKGROUND: The aim of this study is to explore the application value of layered suture technique in two-port laparoscopic choledocholithotomy with primary suture.
MATERIALS AND METHODS: A prospective study of 267 patients received laparoscopic common bile duct choledocholithotomy with primary suture in our hospital from January 2014 to July 2017. Of these cases, layered suture technique was utilised in 110 patients, and single-suture technique was used in 157 patients. The operation time, post-operative hospital stay and post-operative complications were compared between the two groups.
RESULTS: Two groups of patients were operated smoothly, with no conversations to laparotomy. Post-operative recovery was symptom free. The operative time was not significantly different between the two groups of patients (t = -'0.587,P= 0.086). The post-operative hospital stay and incidence of post-operative bile leakage were significantly lower in layered suture group than those in single-layer suture group ([7.6 ± 1.8] days vs. [5.8 ± 1.7] days, t = 2.776,P= 0.000; 4.5% [5/110] vs. 20.4% [32/157], χ2 = 9.885,P= 0.002). In the single-layer suture group, the incidence of post-operative bile leakage was significantly higher in patients complicated with acute cholangitis (44.4% [12/27] vs. 15.4% [20/130], χ2 = 11.634,P= 0.001), whereas in the layered suture group, the incidence of post-operative bile leakage was insignificantly different among patients with and without acute cholangitis (11.8% [2/17] vs. 3.2% [3/93], χ2 = 0.848,P= 0.357).
CONCLUSION: Application of layered suture technique in laparoscopic choledocholithotomy with primary suture is feasible and safe, with advantages of less bile leakage and shorter hospital stay.

INTRODUCTION

With the application of laparoscopic technique, choledocholithotomy has become a widely used technology.[12] Common bile duct primary suture has become the development direction of laparoscopic surgery for its shorter hospital stay and can avoid T-tube's discomfort.[3] Moreover with the development of choledochoscope and its application technology, the residual rate of post-operative biliary calculus has been obviously decreased.[4] Thus, post-operative bile leakage and common bile duct stricture have become the main concerns of the common bile duct primary suture. To reduce post-operative bile leakage, we performed layered suture technique in two-port laparoscopic choledocholithotomy with primary suture and achieved good results. This study was prospectively analysed 267 cases of clinical data of laparoscopic choledocholithotomy with primary suture. And now, we present the study in the following sections.

MATERIALS AND METHODS

Materials

This was a prospective study in patients from January 2014 to April 2017, a total of 267 patients had undertaken laparoscopic choledocholithotomy, from January 2014 to September 2015, we performed only single-layer suture (157 cases) and from October 2015 to July 2017, we performed only layered suture (110 cases). There were 92 male and 175 female patients with a mean age of 63 (range, 27–88) years. Pre-operative choledocholithiasis was diagnosed by computed tomography or magnetic resonance cholangiopancreatography (MRCP). In single-layer suture group, there are 109 cases of digestive symptoms such as abdominal distension abdominal pain, 107 cases of pre-operative jaundice with a mean total bilirubin level of 47.6 umol/L (range, 21.3–234.6 umol/L, 5.1–19.0 umol/L was normal in our hospital) and mean direct bilirubin level of 39.7 umol/L (range, 8.5–210.3 umol/L, 0–7.1 umol/L was normal in our hospital), 106 cases of common bile duct stone with gallbladder stone, 26 cases of simple choledocholithiasis, 27 cases of single stone of choledocholithiasis and 105 cases of multiple stones of choledocholithiasis. The size of stones ranged from 0.3 to 1.9 cm, and the diameter of common bile duct ranged from 0.5 to 1.9 cm. In layered suture group, there are 82 cases of digestive symptoms such as abdominal distension abdominal pain, 65 cases of pre-operative jaundice with a mean total bilirubin level of 46.7 umol/L (range, 19.9–228.1 umol/L) and mean direct bilirubin level of 40.9 umol/L (range, 8.9–212.7 umol/L), 74 cases of common bile duct stone with gallbladder stone, 17 cases of simple choledocholithiasis, 20 cases of single stone of choledocholithiasis and 70 cases of multiple stones of choledocholithiasis. The size of stones ranged from 0.3 to 1.8 cm, and the diameter of common bile duct ranged from 0.5 to 1.8 cm. No statistical difference was reported between the two groups [P > 0.05, Table 1].

Table 1

General characteristics of the studied population

Groups	Single-layer suture group	Layered suture group	t/χ2	P
Age	61.5±14.4	62.4±13.4	−0.139	0.891
Gender	157	110
Male	59	33	1.645	0.200
Female	98	77
Number of stones	2.8±1.6	2.7±1.5	−0.224	0.790
Acute cholangitis	27	17	0.143	0.706
Jaundice	107	80	0.645	0.422
History of biliary tract operation	19	14	0.023	0.879

The study was approved by the Ningbo Medical Center of Lihuili Hospital Ethical Committee. Written informed consent was obtained from the patients. Fitness to surgery included common bile duct diameter ≥5 mm and <20 mm; no distal bile duct obstruction; calculi could be completely removed by choledochoscope; without hepatolith; without polyps or neoplasm in common bile duct.

Methods

All operations were performed by the same surgeon. The patient was intubated in a supine position with a 20° head-up tilt. After undergoing tracheal intubation and induction of general anaesthesia, a CO2 pneumoperitoneum was created via an open Veress-assisted technique. A 30° telescope was used to inspect the peritoneal cavity. Two trocars were used as follows: one 10-mm telescope trocar was placed in the midline above/below the umbilical incision; one 5-mm trocar placed 2 cm below the xiphoid process [Figure 1]. Three needles were used to suspend the gallbladder, one for hanging the fundus of gallbladder and the other two for hanging the neck of gallbladder [Figure 2]. The three needles were used for intra-operative pulling by the first aider to achieve the purpose of exposing surgical vision [Figure 3]. Suturing and knotting were completed at the 5-mm trocar [Figure 4a and b]. In single-layer suture group, routine cholecystectomy, explore the common bile duct and then longitudinal incise the anterior wall of the common bile duct, completely remove the calculus by choledochoscope, continuously single-layer suture the anterior wall of the common bile duct by 4-0 prolene needle, place a drainage tube under the liver. In layered suture group [Figure 4c], routine cholecystectomy, incise proserosa of common bile duct, explore the common bile duct and then longitudinally incise the anterior wall of the common bile duct, completely remove the calculus by choledochoscope [Figure 5], respectively, continuously single-layer suture the anterior wall and proserosa of common bile duct by 4-0 prolene needle, place a drainage tube under the liver. No stent was used in either of the groups.

Figure 1

Placement of the two ports

Figure 2

Three needles were used to suspend the gallbladder, one for hanging the fundus of gallbladder, and the other two for hanging the neck of the gallbladder

Figure 3

The three needles were used for pulling by the first aider to achieve the purpose of exposing intraoperative surgical vision

Figure 4

Intraoperative photo of layered-suture technique for using only one trocar. (a) suturing; (b) knotting (c) primary suture completed. Blue arrow: common bile duct. Yellow arrow: proserosa of common bile duct

Figure 5

Intra-operative photo of using choledochoscope under one port

Observational index

Observational index included operation time (from skin incision to skin suture), volume of post-operative abdominal drainage, post-operative hospital stay and bile leakage rate.

Follow-up

Patients were followed up with phone or outpatient until June 2017.

Statistical analysis

Data were analysed using SPSS for Windows version 20 (IBM Ltd., Armonk, NY, USA). Qualitative variables were analysed by calculating absolute and relative frequencies and were compared with the Chi-square test. Quantitative variables were expressed as mean or median and standard deviation and compared with the Student's t-test. Statistical significance was considered for values of P < 0.05.

RESULTS

The two groups’ operations were performed smoothly. All the patients could get up and move around and eat semi-liquid food on the day after operation. The operation time between two groups had no statistical difference, while post-operative hospital stay and bile leakage rate had statistical difference [Table 2]. In single-layer suture group, the post-operative bile leakage rates in patients with acute cholangitis were significantly higher than the patients without acute cholangitis (44.4% [12/27] vs. 15.4% [20/130], χ2 = 11.634, P = 0.001). In layered suture group, the post-operative bile leakage rates in patients with acute cholangitis had no statistical significant difference with the patients without acute cholangitis (11.8% [2/17] vs. 3.2% [3/93], χ2 = 0.848, P = 0.357), [Table 3]. Bile leakages had disappeared after the unobstructed drainage, the quantity of bile leakage was 20–100 ml/d, duration of 3–10 days and no surgery again. Post-operative pathology diagnosis was in accordance with pre-operative one.

Table 2

Comparison of perioperative index between two groups

Groups	Layered suture group	Single-layer suture group	t/χ2	P
Operation time	85.5±15.6	87.4±18.4	−0.086	0.587
Post-operative hospital stay	7.6±1.8	5.8±1.7	2.776	0.000
Post-operative bile leakage	24	3	9.885	0.002

Data are presented as n (%) or median (range)

Table 3

The influence of acute cholangitis to bile leakage

Groups	Post-operative bile leakage	No post-operative bile leakage	t/χ2	P
Single-layer suture group
Acute cholangitis	12	15	11.634	0.001
Without acute cholangitis	20	110
Single-layer suture group
Acute cholangitis	2	15	0.848	0.357
Without acute cholangitis	3	90

Followed up in single-layer suture group, two cases died of other diseases and lost to follow-up, other 155 cases were followed up for an average 29.2 months (range, 4–72 months). Five cases had calculus recurrence average 37.6 months (range, 17–49 months) after surgery, among them three cases underwent laparoscopic surgery again for stone >1 cm and 2 cases underwent EST treatment for stone <1 cm. Followed up in layered suture group, 110 cases were followed up for an average 13.7 months (range, 4–24 months). One case had a solitary calculus recurrence (<1 cm, about 9 mm × 8 mm) 15 months after surgery, which received EST treatment. Both groups had no complications such as post-operative residual stones, bile duct stricture, post-operative bleeding, abdominal abscess are some of these.

DISCUSSION

Indications for laparoscopic choledocholithotomy

With the development of laparoscopic technique, indications for laparoscopic choledocholithotomy had significantly widened.[5] Anyone who can tolerate the laparoscopic choledocholithotomy is feasible to this procedure, anyone who cannot tolerate the CO2 pneumoperitoneum could undergo gasless laparoscopic surgery. The success rate of laparoscopic biliary tract reoperation is greatly increased in whom had a history of bile duct surgery.[67]

Indications for laparoscopic choledocholithotomy with primary suture

Primary suture could be used in cases that the distal common bile duct stone and the obstruction were completely eliminated.[89] Our measures and experience to prevent stone residues: (1) routine MRCP test before the operation to clear the number of stones preliminary which might be helpful in operation. (2) The skilled application of intra-operative choledochoscope. Place a T-tube if it is not clear whether the stone is totally removed or not, and bile duct detection by choledochoscope postoperatively. (3) Using Holmium laser lithotripsy under choledochoscope if there were impaction of the common bile duct. Application of holmium laser should maintain laser is located in the centre of the stone, be careful of successive energising and pressurised water filling under choledochoscope can keep vision clear. Avoid common bile duct damage and place a T-tube in case of an accident.

Post-operative complications

Bile leakage is the most common complication (15.3%, 24/157) in single-layer suture group, which may be related to our wide indications for patients selection. Bile leakage rates in single-layer suture group patients complicating acute cholangitis were up to 44.4% (12/27), considering the bile duct wall oedema and brittle with acute cholangitis and caused the eye of the needle enlarged when suturing the bile duct wall, which is also related with the incision alignment of the common bile duct was become flabby when acute dropsy abates and duodenal papilla oedema caused the high pressure of the common bile duct. Application of layered suture technique could effectively avoid the possibility of bile leakage caused by the enlarged needle eye and flabby incision alignment. The bile leakage of the layered suture group and which combined with acute cholangitis were decreased to 3.2% (3/93) and 11.8% (2/17). The study suggests that the post-operative bile leakage rate in single-layer group accompanying acute cholangitis was higher than without accompanying acute cholangitis (χ2 = 11.634, P = 0.001), whereas in layered suture group, there was statistically significant difference (χ2 = 0.848, P = 0.357). Bile leakage had disappeared in both groups after complete drainage, no cases needed reoperation and no cases had clinical symptoms because of post-operative bile duct stricture.

From the above, our experience shows that layered suture technique in two-port laparoscopic choledocholithotomy with primary suture could obviously decrease and avoid post-operative bile leakage and its complications, shorten the hospitalisation time, also can expansion indications for laparoscopic choledocholithotomy with primary suture.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.