To evaluate the role of laparoscopic surgery in the treatment of intrahepatic biliary stones, an area that is not well-studied. Subjects and methods: A descriptive crosssectional, retrospective study was carried out on a total of 56 patients. Results: 56 patients with intrahepatic biliary stones underwent laparoscopic surgery. The average age was 54.1 ± 12.17. The number of patients with biliary stones in over 2 segments of liver was 62.5%. The average time of operation was 145 ± 20.37 minutes. The average time of exploration of bile duct was 61.52 ± 33 minutes. The average blood loss was 55.65 ± 17.69 mL. None of the surgeries required conversion to open surgery. Complication rate was 8.9%. The success rate for stone removal was 81.8 - 100% for stones in the larger ducts (hepatic ducts, anterior ducts, posterior ducts and common bile duct) and 0 - 33.3% for stones in the segmental ducts.
Journal of military pharmaco-medicine n02-2019 INITIAL RESULTS OF LAPAROSCOPIC SURGERY FOR TREATMENT OF INTRAHEPATIC BILIARY STONES Do Son Hai1; Bui Tuan Anh1 Nguyen Quang Nam1; Geraldine Lei Yanlei2 SUMMARY Objectives: To evaluate the role of laparoscopic surgery in the treatment of intrahepatic biliary stones, an area that is not well-studied Subjects and methods: A descriptive crosssectional, retrospective study was carried out on a total of 56 patients Results: 56 patients with intrahepatic biliary stones underwent laparoscopic surgery The average age was 54.1 ± 12.17 The number of patients with biliary stones in over segments of liver was 62.5% The average time of operation was 145 ± 20.37 minutes The average time of exploration of bile duct was 61.52 ± 33 minutes The average blood loss was 55.65 ± 17.69 mL None of the surgeries required conversion to open surgery Complication rate was 8.9% The success rate for stone removal was 81.8 - 100% for stones in the larger ducts (hepatic ducts, anterior ducts, posterior ducts and common bile duct) and - 33.3% for stones in the segmental ducts The average length of postoperative hospital stay was 8.89 ± 2.1 days Conclusion: Laparoscopic surgery is a safe and effective method for the treatment of intrahepatic biliary stones However, it should be combined with electrohydraulic lithotripsy via the Kehr drain postoperatively * Keywords: Intrahepatic biliary stone; Laparoscopic surgery; Electrohydraulic lithotripsy INTRODUCTION Treatment of intrahepatic biliary stones remains a challenge Laparoscopic surgery has gained popularity in recent years, but only few studies have been conducted to study its role in the treatment of intrahepatic biliary stones We conduct this study: To determine the feasibility and effectiveness of this method treatment program in Abdominal Surgery Department, 103 Military Hospital from May 2013 to March 2015 * Selection criteria: Only intrahepatic biliary stones alone or both intrahepatic and extrahepatic biliary stones, standardized technique of surgery, availability of research data Methods SUBJECTS AND METHODS Subjects 56 patients with intrahepatic biliary stones underwent laparoscopic surgery * Research methodology: Descriptive cross-sectional, retrospective and noncomparative study of prospectively collected data 103 Military Hospital National University of Singapore Corresponding author: Do Son Hai (dosonhai.pr@gmail.com) Date received: 20/12/2018 Date accepted: 25/01/2019 230 Journal of military pharmaco-medicine n02-2019 * Research contents: + Indication: Only intrahepatic biliary stones alone or both intrahepatic and extrahepatic biliary stones; no contraindication to surgery, abdominal insufflations of CO2 and endotracheal anesthesia - Step 3: Dissect the common bile duct and remove any visible stones Further dissect into the common hepatic duct, including the right and/or left hepatic duct Introduce a grasper and a mesh along the common bile duct and retrieve any visible stones in the bile ducts using the grasper through the incision on the common bile duct Open in high position of the bile duct to take advantage of removing stones + Contra-indications: Having any contraindication to surgery, inability to pump CO2 into abdomen, inability to tolerate endotracheal anesthesia + Remove the biliary stones by RandalMirrizi forcep which can be introduced intra-abdominally through the trocar openings on the abdomen - Some clinical and subclinical characteristics: Age, gender, history, site of intrahepatic stones - Indications and contraindications: - Techniques: + The position of patients, preparation of instruments, and arrangement of the surgical team: Patient lies supine on the operating table with legs extended The surgeon stands between the patient’s legs The first assistant stands on the right side of the patient and the second assistant stands on the left side of patient * Equipments: Surgical instruments and laparoscopic devices were prepared preoperatively * Technique: - Step 1: Set trocars and establish pneumoperitoneum via CO2 insufflation The first 10 mm trocar is on the umbilical area The second 10 mm trocar is on the left flank or left upper quadrant The first mm trocar is on the right flank The second mm trocar is on the epigastric area The fifth trocar, which is used to retrieve the removed biliary stones and insert the Kehr drain, is on the right upper quadrant near the common bile duct - Step 2: Locate the common bile duct and the entire extrahepatic bile duct + Place a catheter into the bile duct and instill water at a sufficiently high pressure to expel the stones + Perform electrohydraulic lithotripsy of the remaining stones through a flexible tube + Conduct an endoscopy check to ensure that all the stones in the common bile duct, common hepatic duct and segmental ducts have been removed - Step 4: Place a 16F Kehr drain into the common bile duct This can be used for electrohydraulic lithotripsy for deep segmental stones later - Step 5: End the surgery by closing the trocar openings on the abdomen + Extra procedures (if indicated): Hepatectomy (cirrhosis, biliary stricture, hepatic abscess), cholecystectomy (gallstones or gallbladder atrophy), choledochojejunostomy if the common bile duct is too narrow * Indicators to assess surgical outcomes: Duration of surgery, blood loss, extra procedures (hepatectomy, cholecystectomy, connect bile duct to small intestine), 231 Journal of military pharmaco-medicine n02-2019 incidence rate, complications, clearance rate of stone, length of postoperative hospital stay * Data processing: Using Epi.info 7.1.5 software RESULTS AND DISCUSSION Some clinical and subclinical characteristics - Number of patients studied: 56 - Age ranged from 28 - 78, with an average of 54.1 ± 12.17 years old - Gender: female/male = 30/26 (1.15) - The position of the intrahepatic biliary stones Table 1: Location of intrahepatic biliary stones Location of intrahepatic biliary stones Number of patients Rate (%) Right hepatic duct 11/56 19.6 Left hepatic duct 18/56 32.1 Right anterior duct 15/56 26.8 Right posterior duct 11/56 19.6 Segmental duct I 3/56 5.4 Segmental duct II 27/56 48.2 Segmental duct III 16/56 28.6 Segmental duct IV 6/56 10.7 Segmental duct V 17/56 30.4 Segmental duct VI 12/56 21.4 Segmental duct VII 17/56 30.4 Segmental duct VIII 19/56 33.9 The distribution of stones in most intrahepatic bile ducts was relatively uniform, with the rate ranging from 19.6 33.9% Howerver, segmental ducts I and IV had lower rate of stone formation at 5.4% and 10.7%, respectively and segmental 232 duct II had the highest incidence of stone formation at 48.2% 8/56 patients (14.3%) had only intrahepatic stones The number of patients with both intrahepatic stones and common bile duct stones was 41/56 (73.2%) The number of patients with intrahepatic stones, common bile duct stones and gallstones was 7/56 (12.5%) Position of the intrahepatic biliary stones according to segmental ducts Table 2: Position of the intrahepatic biliary stones based on the number of ductal segments involved Number of patients Rate (%) Stones in segmental duct 10.7 Stones in segmental ducts 15 26.8 Stones in more than segmental ducts 35 62.5 56 100 Position More patients had stones found in more than segmental ducts compared to those with stones in just segmental duct (p < 0.01) 62.5% of cases had stones in more than segmental ducts Results of laparoscopic surgery for treatment of intrahepatic billiary stones * Duration of surgery: Is calculated from the establishment of pneumoperitoneum to skin closure of the trocar openings The average operating time was 145 ± 20.37 minutes, with the shortest being 60 minutes and the longest being 280 minutes By contrast, the average surgical time in Yoong Ki Kim et al’s study was 278.4 344.3 minutes [9] However, we did not Journal of military pharmaco-medicine n02-2019 try to take out all of deep segmental stones We used electrohydraulic lithotripsy through the Kehr drain to remove the remaining stones * Time taken to locate the main biliary ducts: 15 - 155 minutes; average time: 61.52 ± 33 minutes * Amount of blood lost during surgery: - 160 mL; average: 55.65 ± 17.69 mL The rate of surgical complications was 5/56 (8.9%) There were no serious complications According to Dang Tam, 1,123 out of 8,612 patients who underwent biliary stones operation had complications (13%) The mortality rate of open surgical biliary stones was - 11% [2] * Clearance rate of stone: Table 5: * Rate of conversion to open surgery: 0/56 (0%) Number of patients Rate (%) * Extra procedures: Right hepatic duct 11/11 100 Table 3: Left hepatic duct 18/18 100 Right anterior duct 15/15 100 Right posterior duct 9/11 81.8 Number of patients Rate (%) Left hepatectomy 5.4 Segmental duct I 1/3 33.3 Cholecystectomy 14.3 Segmental duct II 7/27 25.9 1.8 Segmental duct III 4/16 25.0 Segmental duct IV 0/6 0.0 12 21.5 Segmental duct V 0/17 0.0 Segmental duct VI 0/ 12 0.0 Segmental duct VII 0/17 0,0 Segmental duct VIII 1/19 5,6 Common bile duct, common hepatic duct 48/48 100 Extra procedures Connect bile small intestine duct to Extra procedures were performed in 12 out of 56 cases (21.5%) In comparison, the rate of hepatectomy in intrahepatic stones operation in Ton That Tung’s study was 16.7% [1], 33.3% in Hyung Jun Kwon’s [7] and 0.9% in Choi T.K’s 0.9% [5] Surgical complications Table 4: Complications Number of Frequency patients (%) Duodenum’s serosa injury 1.7 Colon’s serosa injury 3.6 Biliary leakage 3.6 8.9 Total The rates of clearance of stone in large bile ducts (right and left hepatic duct, right anterior duct) were all 100% The rate of right posterior duct was 81.8% The segmental duct I, II, III, VIII had low rate of clearance Billiary stones in the segmental duct IV, V, VI, VII could not take all out According to some studies, the rate of postoperative unremoved stones in all billiary open approach was generally - 27%, and for intrahepatic 233 Journal of military pharmaco-medicine n02-2019 stones operation was 46 - 67% [4, 6, 8] According to Tran Dinh Tho, the rate of clearance of intrahepatic stones via the open approach, guided by ultrasound and biliary endoscopy was 64.2% [3] We deliberately left stones in more distal segmental ducts as these stones could be removed via electrohydraulic lithotripsy through the Kehr drain after - weeks postoperatively The average length of postoperative hospital stay was 8.89 ± 2.1 days CONCLUSION - Laparoscopic surgery for treatment of intrahepatic biliary stones was feasible: The operation time was not long, ranging from 60 - 280 minutes The average time was 145 ± 20.37 minutes The average time for locating the main bile ducts was 61.52 ± 33 minutes Blood loss was minimal, with the average amount being 55.65 ± 17.69 mL The conversion rate to open surgery was 0% - Laparoscopic surgery for treatment of intrahepatic biliary stones was effective and safe: The complication rate was 8.9%, including minor complications that could be easy to solve, and there were no major complications Clearance rate of stones in the large bile ducts was high at 81.8 - 100% Postoperative hospital stay was short, with an average duration of 8.89 ± 2.1 days 91.1% of patients had good outcome at discharge Unremoved stones in some segmental ducts were taken out using electrohydraulic lithotripsy through the Kehr drain in - weeks postoperatively 234 REFERENCES Bui Tuan Anh Study of percutaneous biliary drainage technique for treatment of biliary stones Medical Doctor Thesis VMMU, Hanoi 2008 Dang Tam Study the role of percutaneous transhepatic electrohydraulic lithotripsy Medical Doctor Thesis Hochiminh Medical University 2004 Tran Dinh Tho Combine endoscopy and ultrasound in operation to treat intrahepatic biliary stones Medical Doctor Thesis Hanoi Medical University 2006 Aguirre-Olmedo, Adolfo Cuendis-Velazquez et al Laparoscopic choledochoduodenostomy as an optional treatment for complex choledocholithiasis Cir 2014, 81, pp.111-116 Choi T.K et al Current management of intrahepatic stones World J Surg 1990, 14, pp.487-491 Guru Trikudanathan, Mustafa A Arain Advances in the endoscopic management of common bile duct stones Nature Reviews Gastroenterology & Hepatology 2014, pp.535-544 Hyung Jun Kwon, Sang Geol Kim Surgical treatment for intrahepatic duct stones Korean Journal of Pancreas and Biliary Tract 2012, 17 (2), pp.19-27 Xiaoming Ye, Kaiyuan Ni, Xiaoshuai Zhou Laparoscopic versus open left hemihepatectomy for hepatolithiasis JSR Journal Surgical Research 2015, Volume 199, Issue 2, pp.402-406 Yoong Ki Kim, Ho Seung Han, Yoo Seok Yoon, Jai Young Cho Laparoscopic approach for right-sided intrahepatic duct stones: A comparative study of laparoscopic versus open treatment World Journal of Surgery 2015, Volume 39, Issue 5, pp.1224-1230 ... average of 54.1 ± 12.17 years old - Gender: female/male = 30/26 (1.15) - The position of the intrahepatic biliary stones Table 1: Location of intrahepatic biliary stones Location of intrahepatic biliary. .. with intrahepatic stones, common bile duct stones and gallstones was 7/56 (12.5%) Position of the intrahepatic biliary stones according to segmental ducts Table 2: Position of the intrahepatic biliary. .. incidence of stone formation at 48.2% 8/56 patients (14.3%) had only intrahepatic stones The number of patients with both intrahepatic stones and common bile duct stones was 41/56 (73.2%) The number of