Ann Hepatobiliary Pancreat Surg.  2025 May;29(2):192-198. 10.14701/ahbps.25-010.

Usefulness of intraoperative choledochoscopy in laparoscopic subtotal cholecystectomy for severe cholecystitis

• Zhang RH
• Wang XN
• Ma YF
• Tang XQ
• Lin MJ
• Shi LJ
• Li JY
• Zhang HW

• KMID: 2568268
• DOI: http://doi.org/10.14701/ahbps.25-010

Abstract

Laparoscopic subtotal cholecystectomy (LSC) has been a safe and viable alternative to conversion to laparotomy in cases of severe cholecystitis. The objective of this study is to determine the utility of intraoperative choledochoscopy in LSC for the exploration of the gallbladder, cyst duct, and subsequent stone clearance of the cystic duct in cases of severe cholecystitis. A total of 72 patients diagnosed with severe cholecystitis received choledochoscopy-assisted laparoscopic subtotal cholecystectomy (CALSC). A choledochoscopy was performed to explore the gallbladder cavity and/or cystic duct, and to extract stones using a range of techniques. The clinical records, including the operative records and outcomes, were subjected to analysis. No LSC was converted to open surgery, and no bile duct or vascular injuries were sustained. All stones within the cystic duct were removed by a combination of techniques, including high-frequency needle knife electrotomy, basket, and electrohydraulic lithotripsy. A follow-up examination revealed the absence of residual bile duct stones, with the exception of one common bile duct stone, which was extracted via endoscopic retrograde cholangiopancreatography. In certain special cases, CALSC may prove to be an efficacious treatment for the management of severe cholecystitis. This technique allows for optimal comprehension of the situation within the gallbladder cavity and cystic duct, facilitating the removal of stones from the cystic duct and reducing the residue of the non-functional gallbladder remnant.

Keyword

Laparoscopic cholecystectomy; Gallstones; Biliary tract diseases

Figure

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  Fig. 1 A choledochoscope was introduced into the gallbladder orifice via the 12-mm port in the upper abdomen to visualize the inner lumen morphology of the gallbladder and the cyst duct.

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  Fig. 2 A pyramid-type adsorber was attached to the end of the choledochoscope, which might facilitate navigation through the narrow portion of the gallbladder and the Heister fold of the cyst duct: (A) a narrow ring was observed in the gallbladder cavity, which was morphologically similar to the cystic duct orifice. (B) With the aid of the conical absorber, the gallbladder cavity located beneath the narrow ring was observed through choledochoscopy. (C) With the aid of conical adsorber, choledochoscopy allows for the observation of the condition of the cystic duct in a systematic manner through the Heister fold.

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  Fig. 3 The spiral fold was excised in a gradual manner until the root was reached, with direct visualization facilitated by the use of a blend current: (A) the presence of impacted stones within the cyst duct was identified through the use of a choledochoscope. (B) The spiral fold was cut by using a high-frequency needle knife.

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  Fig. 4 The larger stones were fragmented using a plasma shock wave lithotripter.

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  Fig. 5 Residual stones were no longer visible and bile flow from the distal cyst duct was observed under choledochoscopy.

Reference

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