Porcine Aorto-Renal Artery (PARA) model for laparoscopic transcystic common bile duct exploration: the evolution of a training model to meet new clinical needs

Abstract

Background: The transcystic approach to laparoscopic common bile duct exploration has gained popularity for the single-stage management of choledocholithiasis with concomitant gallstones. Our team previously described the use of a porcine aorta segment to simulate the common bile duct during laparoscopic skill training.

Methods: With the advent of the transcystic approach as a contender for the first-line technique of accessing the common bile duct, we present an evolution of the laparoscopic training model using a Porcine Aorta-Renal Artery (PARA) specimen to simulate the structural integrity, dimensions and spatial distribution of both the human cystic and common bile ducts.

Results: This training model allows the use of a choledochoscope for transcystic exploration of the biliary tree. It combines fidelity and reproducibility required for a simulated training model to offer experience in laparoscopic transcystic common bile duct exploration. Validation of the model was demonstrated by 21 surgeons who completed a questionnaire after performing the simulated procedure. In all sections assessing reliability, face validity and content validity of the model, mean rating scores were between 4 and 5 out of five (good or excellent).

Conclusions: We present the evolution of an established training model for laparoscopic common bile duct exploration which focusses the attention on the transcystic approach to the common bile duct and the use of lithotripsy techniques. The need for such a model reflects the shift in the current practice of the laparoendoscopic management of choledocholithiasis with concomitant gallstones from transductal to transcystic approach.

Keywords: Choledocholithiasis; Common bile duct stones; Laparoscopic common bile duct exploration; Laparoscopic transcystic common bile duct exploration; Porcine Aorta-Renal Artery model.

Fig. 1

Preparation of the model. a Anti-clockwise rotation of the left renal artery and kidney. b The suprarenal aorta is ligated at the level of the renal arteries (brackets = simulated anatomical structure). c The right renal artery is raised by placing a 40-mm piece of cork board under the hilum of the right kidney to simulate the in vivo angle of the cystic duct related to the common bile duct. CD, cystic duct; CHD, common hepatic duct; IR, infrarenal; CBD, common bile duct; *ligation of the suprarenal aorta

Fig. 2

Laparoscopic transcystic common bile duct exploration using a 3-mm choledochoscope. a Cannulation of the cystic duct. b Choledochoscopy (distal view of common bile duct). CD, cystic duct; CHD, common hepatic duct; CBD, common bile duct

Fig. 3

Proximal choledochoscopy using a 3-mm choledochoscope. a Laparoscopic view of proximal CBD cannulation. b Accompanying choledochoscopic view of left kidney hilum simulating intrahepatic ducts. c Selective cannulation of an intrahepatic duct with guidewire. d Stone fragmentation with holmium laser lithotripsy (HLL). e Simulation setup with monitor for choledochoscopy (left) and laparoscopic monitor (right)