Clinical Analysis Of Laparoscopic Reoperation In Treatment Of Intra-and Extrahepatic Bile Duct Stones

Objective: The reoperation of laparoscopic biliary tract surgery was reported in few literatures at home and abroad.It has more operation risk and difficulties than the operation performed for the first time.The aim of the study was to evaluate the feasibility,safety,indications,contraindications,technical features and clinical application value of laparoscopic reoperation in treatment of intra-and extrahepatic bile duct stones,and to provide important basis for its promotion.Methods: Clinical data was retrospectively analyzed in 37 cases undergone laparoscopic reoperation in treatment of intra-and extrahepatic bile duct stones in Yijishan hospital of Wannan Medical College between February 2012 and October 2016.All patients had previous biliary tract surgery before this operation.The type of reoperation included: 29 cases of patients received laparoscopic common bile duct exploration;5,laparoscopic hepatic left lateral lobectomy;2,laparoscopic left hemihepatectomy;and 1,laparoscopic hepatic duct jejunum Roux-en-Y anastomosis.The abdominal cavity adhesions were separated with ultrasonic knife and other instruments,then porta hepatis and extrahepatic duct were appeared.Cases performed choledochotomy were performed primary closure or T-tube drainage.The duration of the operation,rate of conversion, rate of stone clearance,intraoperative blood loss,postoperative complications,time of abdominal cavity drainage,postoperative hospital stay,and cost were enrolled.The duration of the operation,postoperative complications,and postoperative hospital stay related factors were confirmed by univariate analysis.Patients were followed up by outpatient service and telephone.Results: The procedure was successfully performed in 33 cases,and 4 cases were conver-ted to open laparotomy.The rate of conversion was 10.8%(4/37).The causes of conversion were: 2 with subhepatic dense adhesions,1 with fistula between common bile duct and duodenum,and 1 with impacted stone in the confluence of left and right hepatic duct.23 cases were performed T-tube drainage and 10 with primary closure.The rate of stone clearance,operative time,intraoperative blood loss,time of abdominal cavity drainage,postoperative hospital stay,the total length of hospital stay and cost was 94.6%(35/37),(199.9±88.9)min,(128.6±65.8)ml,(8.5±5.3)days,(10.0±5.4)days,(15.8±6.0)days,and(30074.1±12036.2)yuan,respectively.10 case developed complications with the rate of 27.0%(10/37).All with no death case.1 case of patient developed ascites;4(10.8%,4/37),intra-abdominal hemorrhage;2(5.4%,2/37),bile leakage;1,venous thrombosis of the lower extremity;and 2,incision fat necrosis.All cured by non-surgical approaches,except 1 case of severe bile leakage and 1 case of intraabdominal hemorrhage by surgical approaches.In 33 cases of patients underwent laparoscopic surgery,univariate analysis showed that intrahepatic stones could result in prolonged duration of the operation(P<0.05);Intrahepatic stones,history of open biliary surgery resulted in more postoperative complications(P<0.05);Patients with a history of open biliary surgery had a prolonged postoperative hospital stay(P<0.05).However,the selection of T-tube drainage or primary closure,operation time interval,multiple biliary surgery,with internal medicine diseases,age,preoperative jaundice,and a high preoperative serum aminotransferase level had no obvious effect on the result of the laparoscopic reoperation(P>0.05).Stone recurrence(3.1%,1/32)was observed in 1 patient and cholangitis in another patient during a mean follow-up of(17.8±11.4)months.Conclusion: In base of selecting cases strictly,laparoscopic reoperation in treatment of intra-and extrahepatic duct stones is feasible,safe and effective,with a high clinical application value.However,surgoens should pay attention to the prevention and therapy of postoperative complications.