Thulium laser-assisted laparoscopic management of intrahepatic stones in recurrent pyogenic cholangitis: A case report and review of minimally invasive approaches

Abstract

Introduction: Recurrent pyogenic cholangitis (RPC) presents significant management challenges, particularly when complicated by large intrahepatic stones. While thulium laser technology has demonstrated excellent results in urological stone treatment, its application in biliary stones remains relatively unexplored. We present a novel approach utilizing laparoscopic choledochoscopy with thulium laser lithotripsy for managing intrahepatic stones in RPC.

Case presentation: A 65-year-old female presented with a two-year history of recurrent right upper quadrant pain, fever, and jaundice. Diagnostic imaging revealed multiple large intrahepatic stones without any liver atrophy or mass lesions. After initial ERCP for acute cholangitis management, the patient underwent laparoscopic choledochoscopy with thulium laser lithotripsy. The procedure included stone fragmentation, extraction, and choledochoduodenostomy for long-term biliary drainage. The procedure was successfully completed with minimal blood loss and no intraoperative complications. At 6-month follow-up, the patient remained asymptomatic with normal liver function, despite small retained stones.

Discussion: This approach combines the benefits of minimally invasive surgery with advanced laser technology. Thulium laser offers potential advantages over conventional lithotripsy methods, including enhanced precision and reduced risk of bile duct injury. The successful outcome in this case suggests that this technique may be a viable option for complex hepatolithiasis in RPC.

Conclusion: Laparoscopic choledochoscopy with thulium laser lithotripsy represents a promising minimally invasive option for managing intrahepatic stones in RPC. While our case demonstrates technical feasibility, long-term follow-up and larger studies are needed to fully evaluate its efficacy.

Keywords: Hepatolithiasis; Intrahepatic stones; Laparoscopic surgery; Recurrent pyogenic cholangitis; Thulium laser lithotripsy.

Fig. 1

Computed tomography findings in recurrent pyogenic cholangitis. (A) Coronal and (B) axial contrast-enhanced CT images of a 65-year-old female with recurrent pyogenic cholangitis. Multiple hyperdense structures (white arrows) are visible within diffusely dilated intrahepatic ducts and common bile duct, consistent with pigmented stones. Note the widespread biliary dilatation, a hallmark of recurrent pyogenic cholangitis.

Fig. 2

Magnetic resonance imaging of hepatolithiasis. (A) Coronal and (B) axial T2-weighted MRI images demonstrating multiple hypointense filling defects (white arrows) within dilated intrahepatic ducts. The largest stone, measuring 3.3 × 5.6 cm, is visible in the right intrahepatic duct. T2-weighted images provide excellent contrast between the hyperintense bile and hypointense stones.

Fig. 3

Key steps in laparoscopic choledochoscopy and stone extraction. (A) Laparoscopic view of choledochotomy using scissors. (B) Extraction of small stones from the common bile duct using grasping forceps. (C) Choledochoscopic view of a large intrahepatic stone. (D) Thulium laser fiber (blue light) directed at the stone surface during lithotripsy at the hepatic confluence. Note the precision of the laser application. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 4

Thulium laser lithotripsy and choledochoduodenostomy cholangioscopic views of stone fragmentation in the (A) right and (B) left intrahepatic ducts using thulium laser. Note the effectiveness of the laser in breaking down large stones. (C) Laparoscopic view of stone dust removal from the subhepatic area using irrigation and suction. (D) Side-to-side choledochoduodenostomy using 3-0 Vicryl absorbable suture, providing long-term biliary drainage.

Fig. 5

Postoperative CT scan at 6-month follow-up. (A) Coronal and (B) axial contrast-enhanced CT images at 6-month follow-up. Small retained stones (white arrows) are visible, but there is no significant biliary obstruction. The patent choledochoduodenostomy can be appreciated, indicating successful long-term biliary drainage.