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. 2023 Mar;37(3):2367-2378.
doi: 10.1007/s00464-022-09667-z. Epub 2022 Oct 17.

Leveraging access to technology and enhanced surgical technique (LATEST) in laparoscopic bile duct exploration (LBDE)

Lalin Navaratne #  1 , Jasim Al-Musawi #  2 , Kritchai Vutipongsatorn  2 , Alberto Martinez Isla  3
Affiliations

Leveraging access to technology and enhanced surgical technique (LATEST) in laparoscopic bile duct exploration (LBDE)

Lalin Navaratne et al. Surg Endosc. 2023 Mar.

Abstract

Single-stage management of choledocholithiasis with concomitant gallstones consists of performing either laparoscopic bile duct exploration (LBDE) or intra-operative endoscopic retrograde cholangiopancreatography at the same time as laparoscopic cholecystectomy. Transductal LBDE is associated with significantly higher post-operative morbidity, longer operative times and longer hospital stay when compared to transcystic LBDE. The aim of this study was to report the transcystic exploration rate and post-operative outcomes from LBDE before and after implementation of the LATEST (Leveraging Access to Technology and Enhanced Surgical Technique) principles.

Methods: A retrospective review of 481 consecutive patients between February 1998 and July 2021 was performed. Patients were assigned into two groups determined by whether they were operated before or after the implementation of LATEST. Data collected included pre-operative demographic information, medical co-morbidity, pre-operative investigations, and intra-operative findings (including transcystic exploration rate, negative choledochoscopy rate, use of holmium laser lithotripsy and operative time). Outcomes of this study were the transcystic exploration rate, stone clearance rate, conversion to open surgery, post-operative morbidity and mortality, and length of post-operative hospital stay.

Results: The pre-LATEST group contained 237 patients and the LATEST group comprised of 244 patients. Ultra-thin choledochoscopes and holmium laser lithotripsy were used more frequently in the LATEST group (41.4% and 18.4%, respectively). Enhanced surgical techniques (correction of the cystic duct-CBD junction and the trans-infundibular approach) were also performed more frequently in the LATEST group. More patients in the LATEST group received transcystic LBDE (86.1% vs 11.0%, p < 0.0001). The LATEST group had significantly higher stone clearance rates (98.8% vs 93.7%, p = 0.0034), reduced post-operative morbidity and shorter post-operative hospital stay (4 days vs 1 day, p < 0.0001).

Conclusions: LATEST describes four key factors that can be used when performing LBDE. The adoption of LATEST in LBDE is associated with an increased stone clearance, a higher transcystic exploration rate and reduced post-operative morbidity.

Keywords: CBD stones; Choledocholithiasis; Common bile duct stones; Laparoscopic bile duct exploration; Laparoscopic common bile duct exploration; Leveraging access to technology and enhanced surgical techniques.

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Conflict of interest statement

Lalin Navaratne and Alberto Martinez Isla work as consultants for Boston Scientific and Johnson & Johnson. Kritchai Vutipongsatorn and Jasim Al-Musawi have no conflict of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
Four ‘pillars’ of Leveraging Access to Technology and Enhanced Surgical Technique (LATEST)
Fig. 2
Fig. 2
Leveraging Access to Technology (LAT). A, an example of an ultra-thin choledochoscope (pictured: SpyGlass™ Discover, Boston Scientific, Marlborough, MA, USA). B, insertion of a 9.5F access sheath for transcystic access with ultra-thin choledochoscope intubating the cystic duct. C, large common bile duct stone with laser probe in position to perform lithotripsy. D, fragmentation using laser lithotripsy. E, removal of fragments with basket
Fig. 3
Fig. 3
Enhanced Surgical Technique (EST). A-C, correction of the cysticocholedochal angle. D-F, Trans-infundibular Approach (TIA) to the common bile duct
Fig. 4
Fig. 4
LBDE cases 1998 – 2019. Total number of cases (red), transcystic (blue) and % transcystic (black)
See this image and copyright information in PMC

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