Nghiên cứu ứng dụng phẫu thuật nội soi kết hợp nội soi đường mật điều trị sỏi đường mật tt tiếng anh

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF NATIONAL DEFENSE 108 INSTITUTE OF CLINICAL MEDICAL ANDPHARMACEUTICAL SCIENCES VU DUC THU THE S TUDY IN APPLICATION OF LAPAROS COPIC COMON BILE DUCT EXPLORATION COMBINED WITH CHOLANGIOS COPY FOR TREATMENT OF BILIARY S TONE Spe ciality: Digestive Surgery Code : 62720125 SUMMARY OF MEDICAL DOC TORAL THESIS HA NOI – 2020 T HE THESIS WAS DONE AT 108 INSTITUT E OF CLINICAL MEDICAL AND PHARMACEUT ICAL SCIENCES Scientific instructors: Prof.PhD Nguyen Ngoc Bich Assoc.Prof PhD Nguyen Anh Tuan Reviewer 1: Reviewer 2: Reviewer 2: This thesis will be presented at Institute Council at: 108 institute of clinical medical and pharmaceutical sciences Day M onth Year The thesis can be found at: National library Library of 108 Institute of clinical medical pharmacological sciences INTRO DUCTIO N Biliary stone is a common diseaseall over the world In Vietnam, biliary stone is formed locally due to mechanisms of infection of bacteria and parasite Consequently,stone is located everywhere on t he bile ducts, the proportion ofhepatolithiasisis ratherhigh, so it is very difficult to management In 1991, Stoker was the firstsuccessfully performed laparoscopic common bile duct exploration This treatment has takenmany advantages over open surgery such as less pain, quick recovery, small incisions, fewer complications, so it is being widely applied in treatment of biliary stone in the world In Vietnam, laparoscopic common bile duct exploration is still mainly indicated for choledocholithiasis Those who have previous abdominal surgery, urgent surgery, elderly patients, have been proven effective to be good results in the world but being not enough knowledges or still little studied T echnically, at medical facilities in Vietnam, surgeons and surgical equipments are very differentfrom: trocar insertion, path to remove stone, means to extract stone and bile duct reconstruction, etc In addition, the results of studyinglaparoscopic comon bile duct exploration combined to cholangioscopy for biliary stone are incomplete or differences between the studies in terms of success rate, stone clearance, intraoperative injury and complications, In order to clarify t he role oflaparoscopic laparoscopic comon bile duct explorationcombined to cholangioscopy for treatment biliary stone in Vietnam such as: What about the indicat ions?, How about the surgical techniques andthe result of treatment? T he thesis titled “Research onapplication of laparoscopic comon bile duct exploration combined with cholangioscopy for management of biliary stones”has been conducted with the two objectives as follows: Studying indications and techniques oflaparoscopic comon bile duct exploration combined with cholangioscopy for treatment of biliary stones Evaluating the early results of laparoscopic comon bile duct explorationcombined with cholangioscopy for treatment of biliary stones ABO UT TH E TH ESIS Ne w contributions of the thesis The author's research results have made new contributions to the development of the speciality which has scientific significance and high reliability as follows: - Re garding indications: Laparoscopic common bile duct explarion combined with cholangioscopy is the most commonly prescribed for choledocholithiasis with percentage of 73.9% The elective surgery was majority, accounting for 89.2% Indicat ion after the removal of choledocholithiasis via endoscopic retrograde cholangiopancreatography failure was 11.7% The patients with previous abdominal surgery was 36.9%, of which biliary surgery was 16.2% The proportion of elderly patients is up to 38.7% - Re garding te chniques: Percentage of operation performing through trocars was the most common with 75.7% Performing operation because of adhesiolysis was 40.2% of cases, of which 100% of cases with a history of biliary tract surgery need to adhesive surgery Transcholedochal approach was common way t o remove stones which accounted for 90.7% Means for extracting stones by basket was the highest rate, accounting for 43.9% Other means: Mirizzi was 16.8%, electrohydraulic lithotripsy was 27.1% and combination of means was 8.4% Electrohydraulic lithotripsy was carried on 32.7% of cases Reasons for lithotripsy: big stones accounted for 31.4%, incarcereted and cast-shaped stones were 68.6% Kehr drainage was the most populary, accounting for 83.2%; primary closure was 7.5%, and ligating the remnant cystic duct was 9.3% - Re garding early results The success rate of the operation was 96.4% The complete stone clearance rate was 74.8% The rate stone clearance separately by each group: choledocholithiasis was 100%, synchronous choledocholithiasis and hepatolithiasis was 35.7%, the lowest is hepatolithiasis 10% The mean operating time was 133.6 ± 46.3 minutes The mean postoperative hospital stay was 5.9 ± 2.6 days General complications was 10.3%: bile leak 2.8%, int raabdominal abscess 0.9%, pneumonia 6.6% Classification of results: good 64.0%, average 34.2% and poor 1.8% The thesis structure The thesis has the structure of 119 pages, in which, Introduction of pages, Lit erature overview of 38 pages, Research subject s and methods of 19 pages, Research results of 20 pages, Discussion of 37 pages, Conclusion of pages and Recommendations of page The thesis consists of 32 tables, 15 photos and charts The thesis has 126 references, including: 24 ones in Vietnamese, 102 ones in English Chapte r LITERA TUR E O VERVIEW 1.3.5 Laparoscopic common bile duct e xploration for tre atment of biliary stone s In 1991 in Australia, Stoker firstperformed laparoscopic common bile duct exploration for patients have synchronouslycholedocholithiasis and gallblader stone Subsequently, many authors from around the world presentedlaparoscopic common bile duct exploration for choledocholithiasis In Vietnam, in 2000, Nguyen Dinh Song Huy reportedlaparoscopic common bile duct exploration for 25 cases have extrahepatolithiasis combined to gallblader stone T he author did not fill in peritoneal cavity with gas but uses Hashimoto's abdominal lift system and removestone with Mirizzi, closure the choledochotomy by open needle holder, 1.3.5.3 Advantages and disadvantages Advantages: This is minimally invasive surgery so patients recover fast er, less pain, reduce hospital stay, low costs Blood lost in operation is less Because of keeping the Oddi sphincter intact, so that it reduce retrograde infections after surgery In particularly, removing stone via transcystic laparoscopic bile ductexplorationis the least invasive method, keeping the common bile ductintact and fewer wound infection Disadvantages: This methodhave to equips with more surgical facilities and surgeon requires high surgical skills so it is often carried on in large surgical centers Infact that, it canface by many difficulties toperform inhepatolithiasis, previous biliary surgery, urgent situation, cases of contraindications to inflation of peritoneal cavity 1.4 Studying indications and te chniques for laparoscopiccommon bile duct e xploration combine d to cholangioscopy for treatment of biliary stone 1.4.1 Indications 1.4.1.1 In the world Stone location: In developed countries, stone is almost located in common bile duct, sohepatolithiasis is rarely seen Therefore,studies did not mentionto laparoscopic common bile duct exploration for hepatolithiasis In Southeast Asian countries, more than a decade ago, laparoscopic common bile duct exploration for hepatolithiasis has been applied and published research results Hepatolithiasis biliary stenosis is a matter of great concern t o authors when making indications, often contraindicated Timing of surgery: Laparoscopic common bile duct exploration for biliary stone is almost exclusively indicated for selective patients Most of the studies are conducted on schedulepatients, recently some have reported for emergency operations After failed endoscopic re trograde cholangiopancreatography: Intervention to remove stone by endoscopic retrograde cholangiopancreas is not always successful, the failure rate is 4-10% Bansal has an study to compare laparoscopic common bile duct exploration after failed endoscopic retrograde cholangiopancreatographyand the group appointed from the outset T he success rat e of two groups were equal Patients with recurrent hepatolithiasis:in 2008, Chiappetta firsr performed laparoscopic common bile duct exploration for patients with recurrent hepatolithiasis It was safe, highstone clearance Pu conducteda comparative study between conventional surgery and laparoscopic comon bile duct exploration on patients with recurrent hepatolithiasis The results of two methods have the same stone clearance rate, but the laterhave had fewer intraoperative injuries and complications 1.4.1.2 In Vietnam In Vietnam, laparoscopic common bile duct exploration combined with cholangioscopy for treatment of biliary stone has applied from the late 90s of the twentieth century with indications being expanded In 2006, Nguyen Khac Duc indicated patients with choledocholithiasis, recurrent biliary stone, urgent surgery, and after failed endoscopic retrograde cholangiopancreatography In 2007, Nguyen Hoang Bac have expanded indications of laparoscopic comon bile duct exploration for patients with hepatolithiasis, hepatecomy due t o stone, However, the author did not point for emergent surgery 1.4.2 Te chniques 1.4.2.1 In the world So far, laparoscopic common bile exploration has been carried out through two ways: transcholedochal and transcysticapproach T echnical steps to extract transcystic approach include: dissect ion of the cystic duct for recognizing the confluence of the cystic duct withthe common bile duct,longitudinal incision ismade on t he anterior wall of the cystic duct and then insertion of a choledochoscope into the common bile ductto eliminatestone.Technical stepstransductal approach includes:make a choledochotomy on the long axis of the common bile duct, then insert the choledochoscope through choledochotomy to eliminatestone According to Paganini (2007): elimination stone via transcystic approach when the stone size is less than mm and locating below the bifurcat ion of cystic duct and common bile duct Transcholedochalapproach when the stone is over mm in size and the number of stones is more than According to Yoon (2007) and Eric Lai (2010), the steps of laparoscopic common bile duct exploration for eliminating hepatolithiasis is similar to choledocholithiasis All cases of retained stones or suspicous stones are placed Kehr drain 1.4.2.2 In Vietnam In Vietnam, laparoscopic common bile duct exploration combined with cholangioscopy was applied later and there were some differences compared with t he authors in the world In 2000, Nguyen Dinh Song Huy, performed laparoscopic by Hashimoto abdominal lift technique Removing stones from common bile duct with Mirizzi, closurecholedochotomy with open needle holder Technique of Nguyen Khac Duc: placed5 trocar: umbilical port, epigastrium (below xiphoid proccess), left uppper quadrant, right uppper quadrant Intraoperative Cholangiography was performed for 79 (70.1%) cases Intraoperative cholangioscopy underwent was very limited: cases Nguyen Hoang Bac (2007) performed stone extraction via both transcystic and transcholedochal approach, intraoperative cholangioscopy in 99.4% of cases, electrohydraulic lithotripsy in 25.5% of cases 1.5 Studying the early results of laparoscopic common bile duct exploration combined with cholangioscopy for treatment of biliary stone 1.5.1 In the world In developed countries, laparoscopic transcystic common bile duct exploration is very popular According to Berthou (2007): T he success rat e of this method was 75.2%, andlaparoscopic transcholedochal common bile duct exploration was 97.0% T he rate of retained stone was 2.8%, complication 7.9%, mortality 1% Zhu's study had laparoscopic comon bile duct exploration to remove hepatolithiasis The success rate was 83.33%, operating time was 297.7 ± 85.0 minutes Intraoperative stone clearance rate was 66.7% T he hospital stay was 15.0 ± 5.3 days 1.5.2 In Vietnam In 2006, laparoscopic common bile duct exploration for choledocholithiasis of Nguyen Khac Duc showed that: the rate of conversion to open surgery was 14.6%, operating time 150 ± 37 minutes Intraoperative injury 2.75%, retained stone rate 10.25%, hospital stay 9.9 ± 3.3 days Complications 3.91%, caseshad to reoperated According to Nguyen Hoang Bac (2007), the success rat e of laparoscopic common bile duct explorationwas 97.67% Intraoperative stone clearance rate reached 68.45% Chapte r RES EARC H SUBJECTS AND METHO DS 2.1 Subje cts Patients with biliary stone have to perform laparoscopic common bile duct exploration at Vietnamese-Swedish UongBiHospital and University Medical Center HCMC from May 1, 2015 to September 30, 2018 2.1.1 Inclusion crite ria Patients diagnosedbiliary stone by: clinical and imaging and have to perform laparoscopic common bile duct exploration combine to intraoperative cholangioscopy 2.1.2 Exclusion criteria Patients with laparoscopic comon bile duct exploration through a trocar hole, with attached stone liver resection 2.2 Study design Prospective, longitudinal, descriptive study 2.2.1 Sample size The sample size of the study is calculated according to the formula: n  Z12 / P  (1  P) e2 P is the retained stone of laparoscopic common bile duct exploration According to statistics ducumented in some studies in Vietnam, the rate of retained stone ranged from 6.50-10.25%, choosing p = 0.1, instead of the formula we have n = 96 2.2.2 Equiqments Surgical laparoscopic system of Striker or Olympus Cholangioscopic system CHF P20Q and lithotripsy Lithotron EL27compact 2.2.4 Te chnical proce dure 2.2.4.1 Indications and contraindications Indications: Patients have choledocholithiasis, hepatothiasis combined to choledocholithiasis,hepatolithiasis Diamater of common bile duct is more than mm Contraindications: Patients have biliary stones locate only in segmental ducts or further, severe biliary strictures and liver atrophy due to stone Cirrhosis of Child B or more severe, liver cancer, cholangioma, liver abscess, history of entero-biliary anastomosis surgery ASA ≥ 3, cannot be intubated Cholangitis garade III according to the standards of Japanese Associat ion of Hepato-Biliary-Pancreatic Surgery 2018 2.2.4.5 The technical ste ps Ste p 1: Trocar in sertion:four-port access wa s usedstone: port number 1: 10-mm umbilical site for telescope, insufflation and taking out specimens; Port number 2: 10-mm in the leftt midclavicular line below the costal margin; Port number 3: mm in the right midclavicular line below the costal margin; Port number 4: 5-mm working port in the epigastrium near xiphoid In patient have a previous upper abdominal surgery anothe mm port need to place in right or left iliac fossa to help dissecting adhesive Ste p 2: Explorating abdomen and re vealing the biliary tract: observe and evaluate the condition of the liver, gallbladder, common bile duct, inflammation and adhesive surround of portal hepatic region Using a hook make an incision 20 mm longitudinal of peritoneal layer cover common bile duct or common hepatic duct Ste p 3: O pening the biliary tract: make an anterior longitudinal incision ton common bile duct ength of 10-15 mm In case performing transcystic exploration, Calot’s triangle along with cystic duct and the part of gallbladder beyond Calot’s triangle was dissect ed and then make an mm incision logitudinal cystic duct Ste p 4: Re moving stones: T hrough the bile duct opening according to the location, the size of the stone the surgeon uses the different t ools goes into the bile duct to remove the stone from the bile duct Ste p 5: Biliary tract re pairment: Cutting gallbladder if indicated In the case of transcystic exploration, the remnant of cystic duct is klippedor looped if transcholedochal exploration, there are solutions: placeKehr’s tubedrain or primary closure choledochotomy Step 6: Ending the surgery: Irrigation the surgical area, remove gauze, specimens Place drainage below t he liver, closure the trocar’s wound 2.2.4.6 Postope rative management - Postoperative treatment: antibiotics, analgesic and parenteral nutrition - Evaluation of residual stone: based on ultrasound, cholangiography via Kehr drain Patients with retained stone are re-examined after month and remove stone through the Kehr’s tube t unnel 2.3 Accessment standards 2.3.1 Gene ral characteristics: Age, gender, occupat ion and geography Clinical symptoms: right lower quadrant pain, fever, jaundice Combined medical diseases: cardiovascular, respiratory, diabetes and other diseases Hematology and biochemistry 2.3.2 Indications and techniques oflaparoscopic comon bile duct exploration combined with cholangioscopy for tre atment of biliary stone s 12 3.2.1.4 History of abdominal surgery Table 3.8 History of abdominal surgery His tory of abdominal surgery n Rate % Cholecystectomy 4,5 Conventional common bile duct exploration 18 16,2 Appendectomy 2,7 Caesarean 11 9,9 Partial gastrectomy and repair of duodenal ulcer 2,7 perforation Colonectomy 0,9 Total 41 36,9 Comm ents:The most common history of biliary tract surgery was 18 open cases and cases of cholecystectomy totaling 20.7% 3.2.1.5 Elderly patients:The proportion of elderly was 38.7% 3.2.2 The techniques of laparoscopic common bile duct exploration combined with cholangioscopy for treatment of biliary stone There were cases have converted to opened surgery, from here we will analyze techniques and early surgical results in 107 cases 3.2.2.1 Numbe r of trocar Table 9.Numbe r of trocar Numbe r trocars trocars trocars trocars Total n 81 11 107 Rate % 7,5 75,7 10,3 6,5 100 Comm ents:Surgery using trocar has the highest rate of 75.7% 13 3.2.2.2 Adhesion and reave aling common bile duct Table 3.10 Pe rforming adhesiolyosis to re ve al common bile duct His tory of surgery Non history of abdominal surgery Opened common bile duct exploration Cholecystectomy Partial gastrectomy and repair of duodenal ulcer perforation Ceasarean Appendectomy Total n 16 18 Rate % 14,4 16,2 4,5 1,8 1 43 0,9 0,9 40,2 Comm ents:All patients with previous biliary surgery need to to perform adhesiolysis to reveal the common bile duct 3.2.2.3 Approach to e xtract stone Extractingstonetranscholedochal approach had 89,7% and transcystic approach 10,3% There was a case in transcystic approach group have to be converted to opened surgery 3.2.2.5 Me ans of extracting stone Table 3.11 Means of extracting stone Means of extracting stone n Rate % Flushing 2,8 Mirizzi 18 16,8 Basket 47 43,9 Electrohydraulic Lithotripsy 29 27,1 Combining means or more 8,4 Cholangioscopy only 0,9 Total 107 100 In cases of removing stone by combining means there were cases have performed electrohydraulic lithotripsy Comm ents:The basket was the commonest means to removing stone 43.9% 14 3.2.2.6 Cholangioscopyand electrohydraulic lithotripsy Table 3.12 Lesions observed by cholangioscopy Lesions n Rate % Stone 99 92,5 Stone + ascaris lumbricoides 2,8 Stone lived in a biliary sac 0,9 Cholangitis 28 26,2 Biliary Stenosis 5,6 There were cases, stones were extracted fulfilled immediately by Mirizzi, so there was no stone when performed cholangioscopy Comm ents:The cholangioscopy found stones up to 92.5% Table 3.13 Placement of ele ctrohydraulic lithotripsy Placement of electrohydraulic N Rate % lithotripsy Common bile duct 13 37,1 Oddi 14,3 Left hepatic duct 5,7 Right hepatic duct 10 28,6 Left and right hepatic duct 11,4 Se gmental and subsegmetal duct 2,9 Total 35 100 Comm ents:Electrohydraulic lithotripsy for stones locating in common bile duct were commnest 13 (37.1%) The reason of lithotripsy: big stone 24 cases, incarcerated and castshaped stones 11 cases 3.2.2.7 Biliary tract re pairment Table 3.14 Type of biliary tract re pairment Type of re pairment n Rate % Clipping remnant cystic duct 10 9,3 Placing Kehr 89 83,2 Primary closure common bile duct 7,5 Common bile duct Running suture 64 66,0 closure type Interrupted suture 33 34,0 There were 51 cases of cholecystectomy due to gallbladder stone Comm ents:placing Kehr applies up to 89 (83.2%) cases 15 3.2.2.8 Intraope rative injury There was a case having perforation of the duodenum when dissection and immidiately repaired by laparoscopic suture 3.3 Early re sults of laparoscopic common bile duct exploration combined with cholangioscopy for treatmnet biliary stone 3.3.1 Success rate Research had performed successf ullaparoscopic comon bile duct exploration for 107 cases T here were (3.6%) cases have to convert to open surgery due t o the following reasons: one patient could not dissect ed to approach to portal hepatic region T wo patients could be approach t o the portal hepatic region but did not find the common bile duct Of them, all have hadprevious common bile duct exploration before A patient with Oddistricture had to make a small incision in the right uppper quadrant to bilico-entero anastomosis 3.3.3 Stone clearance Table 3.19 Stone clearance rate by location Location of stone Choledocholithiasis (n = 69) Hepatolithiasis(n = 10) Choledocholithiasis combined to hepatolithiasis(n = 28) General (n = 107) n 69 Rate % 100 10,0 10 35,7 80 74,8 Comm ents:the rate of intraoperative stone clearance in patients with choledocholithiasiswas up t o 100% Table 3.20 Location of re sidual stone Location of stone Left hepatic duct and further Righthepatic duct and further T wo of hepatic duct and further Common bile duct and right hepatic duct Se gmental duct Total n 11 27 Rate % 3,7 8,4 10,3 0,9 1,9 25,2 Comm ents:Most residual stone was located intrahepatobiliary tract 16 Table 3.22 Re sidual stone afte r extracting viaKehr tunnel Location of stone Left hepatic tract Right hepatic tract Left hepatic biliary tract + Right hepatic tract Common bile duct Total n 10 Rate % 1,9 0,9 6,5 0,0 9,3 Comm ents:all residual stone was locat ed intrahepatobiliary tract Table 3.23 Final stone extracting result Stone location n Rate % Choledocholithiasis (n = 69) 69 100 Hepatolithiasis (n = 10) 40,0 Choledocholithiasis combined to 24 85,7 hepatolithiasis(n = 28) General (n = 107) 97 90,7 Comm ents:The rate of stone clearance had only reached to 40% for hepatolithiasis, but 100% for choledocholithiasis 3.3.4 Ope ration duration Table 3.24 O pe ration duration Duration n Rate % Average Longest Shortest (minute) 45-60 1,9 >60-90 19 17,8 >90-120 29 27,1 >120-150 29 27,1 133,6 ±46,3 60 300 >150-180 17 15,9 > 180 11 10,3 Total 107 100 Comments:The operation time ranged from 90 to 150 minutes was the most common 54.2% 17 3.3.6 Duration of hospitalization The average duration of hospitalization is 5.9 ± 2.6 days, the shortest is days, the longest is 21 days T he average time for bowel movements is 36.8 hours, the shortest is 16 hours and the longest is 72 hours Kehr draining time averages 28.8 days, t he shortest is 11 days, the longest is 60 days 3.3.7 Complications Table 3.28 Classification of complications Complications n Pneumonia Wound infection + bile leak Bile leak Intra-abdominal infection Total 11 Comm ents:Pneumonia has had the highest rate of 6.5% 3.3.8 Gene ral results Table 3.29 Final re sults Type n Good 71 Moderate 34 Poor Bad Total 107 Rate % 6,5 0,9 1,9 0,9 10,3 Rate % 66,4 31,8 1,8 100 Comm ents:The surgery achieved good results up to 66.4%, only (1.8%) cases achieved poor results, no deaths Chapte r DISCUSSIO N 4.1 Gene ral characte ristics 4.1.1 Age and gender Biliary stone disease can occur at any age The average age of patients in the study was 55.3 ± 16.3, the highest was 93, the lowest was 12, the group of working-age population (30-60 years) accounted 18 to 57.7% In Vietnam, the average age of patients in previous studies was from 41.8 to 46.9 years, of which the proportion of young people is more In recent years, the age of biliary stone tends to older than before The study results showed that the proportion of female patients was 64.9% This ratio is common in domestic and worldwide studies So far, no theory has clearly stated why women have stone disease more than men 4.2 Indications and te chniques of laparoscopic comom bile duct exploration combined with cholangioscopy for treatment biliary stone 4.2.1 Indications 4.2.1.1 Stone location In developed countries, most studies have focused on laparoscopic common bile duct exploration for stone, very little mention of hepatolithiasis In Vietnam, biliary stone is located both in extrahepatobiliary and intrahepatobiliary tract so that laparoscopic comon bile duct exploration is not only indicated for choledocholithiasis but also applied to hepatolithiasis When init ialmaking applications, authors often choose cases of choledocholithiasi, after that’s they will extend the indicat ion to the hepatolithiasis The rate of hepatolithiasis in previous studies was from 5.1% to 33.1% The study have indication for hepatolithiasis accounted to 26.12% 4.2.1.2 Timing of surgery Scheduled operation is the most common indication Recently, there have been reports of emergency laparoscopic comon bile duct exploration for patients with acute cholangitis due to biliary stone However, the indication is limited to non-severe cholangitis The study had 99 (89.8%) casesto be performed in schedule, the rest were emergency operation 12 (10.8%) In our country, the rate of application of laparoscopic common bile duct exploration in the emergency situation was about - 3.65% 19 4.2.1.3 Laparoscopic common bile duct exploration afte r failed endoscopic stone e xtraction In developed country, with the advent oflaparoscopic cholecystectomy, endoscopic retrograde cholangiopancretography has been very popular Choledocholithiasis synchronous with gallbladder stone can be conducted by: laparoscopic cholecystectomy and then endoscopic retrograde cholangiopancretography to extract stone or contrary Endoscopic retrograde cholangiopancreatography extracting stone has a failure rate of - 10%, in case of failure the patient will have to convert to other methods to remove stone, in which laparoscopic common bile duct exploration is one of the first alterations In this study, there were 13 unsuccessful cases of failed endoscopic extracting stone, including: 12 cases could remove stone and onehave remnant stones All these cases have successful performed laparoscopy common bile duct exploration Here, laparoscopic common bile duct explorationplay a roll as a preventive method for endoscopic retrograde cholangiopancretography 4.2.1.4 Recurrent biliary stone The study had 41 (36.93%) cases with a history of open abdominal surgery: common bile duct exploration 18 (16.21%) cases, cholecystectomy (4.50%) cases So far, open surgery for cases withhistory upper abdominal surgery, especially previous biliary operation is still considered standard method In Vietnam, patients with recurrent stonehas been perfomed laparoscopic common bile duct exploration ranged from - 6.57% In Pu's study, comparing laparoscopic comon bile duct explorationto open surgery for recurrent choledocholithiasis The results: operation time and stone clearance rate were equal, but in the open surgery group had more postoperative complications and longer hospital stay 4.2.1.5 Elde rly patients Are laparoscopic common bile duct exploration suitable for the elderly? is a question that is rarely mentioned by Vietnamese researchers The study included 24 (21.6%) cases of people over 70 20 years old, in the age group of 60 and older, there were 43 (38.7%) cases T he proportion of the elderly in the study is relatively high compared to previous studies in the country In Vietnam, many elderly patients have had perfomed laparoscopic common bile duct exploration, but there has not been a separate study for this group The study of Nguyen Hoang Bac has 27.9% of cases over 70 years old undergoinglaparoscopic common bile duct exploration, no deaths after surgery 4.2.2.Te chniques 4.2.2 Trocar insertion The studyused trocar for 81 (75.70%) cases All of them have first time performed common bile duct exploration We want to emphasize the role of the trocar number 4th This is the approach for us t o put Mirizzi or choledoscope into the common bile duct with the shortest distance It help to faciltate extracting stone easier At the end of the surgery, a long branch of Kehr tube will be taken out of the abdominal wall through this port Placing drainage like t hat will create a shortest, non-twisting tunnel that will allow good int ervention to remove stone if any 4.2.2.3 Approach to remove stone In developed countries, laparoscopic common bile duct exploration is carried on through two approachs: transcystic and transcholedochal route Among them, laparoscopic transcystic commonbile duct exploration is the first choice for cases that have synchronouslycommon bile duct stone and gallbladder stone This method can keep intact anatomical structure of the common bile duct The main disadvantage of this method that it is impossible to extract stones live in hepatobiliary The study have performed laparoscopic transcystic common bile duct exploratin for 11 cases There was one case have to convert to cholochotomy due t o having many stones T he characteristics of biliary stone in our country as: big stone, large numbers, proportion of hepatolithiasis is still so high, so that laparoscopic transcholedochal common bile duct exploration is more popular 21 4.2.2.5 Me ans of extracting stone The rate of using stone extracting devices of the study were: Mirizzi16.82%, basket 43.93% and electrohydraulic lithotripsy 27.10% Among them, Mirizzi is a conventional mean to extract stone Advantages of removing stone with Mirizzi as: easy to extract stone located in common bile duct In addition, surgeons are used to handling it in open surgery Disadvantages of using Mirizzi: rather difficult to handle its in cases of patients with thick abdominal wall, incarcerated stone, too large stone, or stones lies far from choledochotomy The rate of using basket to remove stone of this study is higher than previous studies For stones that are out of reach of Mirizzi, removing stone bybasket is more effective The study performed intraoperative electrohydraulic lithotripsy for 35 (32.7%) cases, including 34 cases performed transcholechotomy, there was only one case perform transcystic approach This case had a big stone that could not take out by basket (Table 3.13) The position which we performed electrohydraulic lithotripsy with high frequency is common bile duct (13 cases) There was one case stone lived inbiliary sac near Oddi that discovered and eliminated by lithotripsy successfully The reasons performed electrohydraulic lithotripsy of the studyas follow: big stone to 31.4%, incarcerated and cast-shaped 68.6% T he European-American authors mainly performed electrohydraulic lithotripsy transcystic approach for incarcerated stones in the common bile duct The study performed intraoperative electrohydraulic lithotripsy at all locations on the biliary tract except at the subsegmental duct level 4.2.2.7 Biliary tract re pairment The study had 10 successful cases of removing stonetranscystic common bile duct exploration.The remnant the cystic duct was clipped or intracorporal looped In the choledochotomy group, there were 89 (83.16%) cases to be placedKehr’s t ube The longbranch of Kehr’s t ube was carried out through the 4th trocar port This could facilitate to removal of remnant stone (if any) through t he Kehr’s t ube t unnel later 22 In the last 10 - 20 years, many authors advocated primary closure choledochotomy immediately In the study have had cases to perform primary closure choledochotomy The criteria implementedprimary closure choledochotomy of the study as follow: stone cleared, diameter of common bile duct over mm and little inflammation or no edema in the common bile duct wall 4.2.2.8 Intraope rative injury The study showed case of duodenal perforation while dissect ing dense adhesion of prtal hepatic region This was laparoscopical repaired immediately Postoperatively, there were no leakage In my knowledge, postoperative complications has been published in the literature: bleeding, small int estinal perforation, colon perforation and common bile duct injury 4.3 Early re sults of laparoscopic common bile duct e xploarion combined with cholangioscopic common bile duct e xploration for tre atment of biliary stone 4.3.1 Success rate The rate of successful surgery of the study was 96.40% There were (3.60%) cases have converted to open surgery Reasons for open surgery were: cases, common bile duct could not be found, case was failed to reach hepatic portal region, case was made an small incisionsmall incision in the right uppper quadrant in order to perform bilicoentero anastomosis In addition, surgeon experiences play an important role: in the new period of applying this method to treat choledocholithiasis in Vietnam, the rate of conversion to open surgery was a bout 11.48 - 15.15% Reasons for open surgery included: massive bleeding, biliary injury, incarcerated stone in common bile duct or Oddi 4.3.3 Stone clearance rate Stoneclearance is the central issue of surgery or intervetion in t he treatment of biliary stone The stone clearance of laparoscopic common bile duct exploration combined with cholangioscopy for treatment of choledocholithiasis may reach to 96.7 - 100% T he study had a general intraoperative stone clearance rate of 74.76% All 69 (100%) cases of 23 choledocholithiasis were cleared immediately during surgery Thus, this rate of the study has reached the same level with many recently published studies However, the stone clearance rate decreases rapidly when the stones live in intrahepatobiliary tract In a study of Nguyen Hoang Bac, the intraoperative stone clearance rate of a group with hepatolithiasis was less than 20% We believe that the high rate of residual stone in hepatolithiais is the greatest limitation of the study 4.3.5 Ope rating time The average operation time of the study was 133.60 ± 46.63 minutes similar to the other authors The experiences and skills of the surgeon are important for the length of the surgery At VietDucHospital, the initialperiod of applying laparoscopic common bile duct exploration took average time of surgery was 180 minutes 4.3.7 Hospital stay The average hospital stay in the study was: 5.86 ± 2.56 days, this result is equivalent to the statistics of Nguyen Ngoc Bich Laparoscopic common bile duct is the minimally invasive method that can reducehospital stay and fastpostoperative recovery The level of postoperative pain is less, early rehabilitation functions: motive, gas, feeding, contribute to reducing durat ion of hospitalization In Paganini’s study, the group of patients who had laparoscopic transcystic common bile duct exploration was equivalent to simple laparoscopic cholecystectomy 4.3.8 Complications The most common complication of laparoscopic common bile duct exploration was bile leak (7.8%) This complication is the main reason for reoperation, even death T he study have had (8.7%) casesocc ured bile leak All of them have had low volume leaka ge so that’s no need to carry on intervention, completely solveby medical treatment, however it take longer hospit al stay Wound infect ion was very rare in laparoscopic common bile duct exploration - 1.97% which is an outstanding advantage Pneumonia after surgery wa s the most common complication of study 6.60%, most occured in patients over 70 years of age 24 CONCLUSIO N By studying 111 cases undergoing laparoscopic common bile duct exploration combined with cholangioscopy for treatment of biliary stone atVietnamese-Swe dish UongBiHospital and University Medical Cent er HCMC from May 1, 2015 to September 30, 2018, the research draws the following conclusions: Indications and te chniques of laparoscopic common bile duct exploration combined with cholangioscopy for tre atment of biliary stone Indications Laparoscopic common bile duct explarion combined with cholangioscopy is the most commonly prescribed for choledocholithiasis with percentage of 73.9% The elective surgery was majority, accounting for 89.2% Indicat ion after the removal of choledocholithiasis via endoscopic retrograde cholangiopancreatography failure was 11.7% The patients with previous abdominal surgery was 36.9%, of which biliary surgery was 16.2% The proportion of elderly patients was up to 38.7% Te chniques Percentage of operation performing through trocars was the most common with 75.7% Performing operation because of adhesiolysis was 40.2% of cases, of which 100% of cases with a history of biliary tract surgery need to adhesive surgery Transcholedochal approach was common way t o remove stones which accounted for 90.7% Means for extracting stones by basket was the highest rate, accounting for 43.9% Other means: Mirizzi was 16.8%, electrohydraulic lithotripsy was 27.1% and combination of means was 8.4% Electrohydraulic lithotripsy was carried on 32.7% of cases Reasons for lithotripsy: big stones accounted for 31.4%, incarcereted and cast-shaped stones were 68.6% 25 Kehr drainage was the most populary, accounting for 83.2%; primary closure was 7.5%, and ligating the remnant cystic duct was 9.3% Early results of laparoscopic common bile duct exploration combined with cholangioscopy for treatment of biliary stone Early results The success rate of the operation was 96.4% The complete stone clearance rate was 74.8% The rate stone clearance separately by each group: choledocholithiasis was 100%, synchronous choledocholithiasis and patolithiasis was 35.7%, the lowest washepatolithiasis 10% The mean operating time was 133.6 ± 46.3 minutes The mean postoperative hospital stay was 5.9 ± 2.6 days General complications was 10.3%: bile leak 2.8%, int raabdominal abscess 0.9%, pneumonia 6.6% Final resultS Classificat ion of results: good 64.0%, average 34.2% and poor 1.8% RECO MMENDA TIO NS The laparoscopic common bile duct exploration combined with cholangioscopy is an effective mangement for bilary stone in Vietnam The provincial hospitals should invest in manpower and equipments to implement t his routine treatment to meet t he needs of patients The research design and results only stop at the levels of: describing and evaluating early results Therefore, comparative and controlled studies with other methods and far-reaching evaluation should have a solid scientific basis for effective treatment of biliary stone which is still very difficult in Vietnam TH E PUBLISHED TH ESIS-RELATED RES EARC H PROJECTS Vu Duc T hu, Nguyen Ngoc Bich, Nguyen Anh T uan (2019), “ Indications and techniques of Laparoscopic comon bile duct exploration combined with cholangioscopy and electrohydraulic lithotripsy for treatment of intra and extrahepatolithiasis ”, Journal of 108-Clinical Medicine and Pharmacy, Vol 14, Issue No 5, p.76-82 Vu Duc T hu, Nguyen Ngoc Bich, Nguyen Anh T uan (2019), “ Early results of and electrohydraulic lithotripsy for treatment of intra and extra- hepatolithiasis”, Journal of 108-Clinical Medicine and Pharmacy, Vol 14, Issue No 5, p.89-93 ... PHARMACEUT ICAL SCIENCES Scientific instructors: Prof.PhD Nguyen Ngoc Bich Assoc.Prof PhD Nguyen Anh Tuan Reviewer 1: Reviewer 2: Reviewer 2: This thesis will be presented at Institute Council... been proven effective to be good results in the world but being not enough knowledges or still little studied T echnically, at medical facilities in Vietnam, surgeons and surgical equipments are... hepatolithiasis has been applied and published research results Hepatolithiasis biliary stenosis is a matter of great concern t o authors when making indications, often contraindicated Timing of surgery: