Abstract: Objective:To investigate the application value of ligamentum teres hepatis approach in laparoscopic biliary reoperation.
Methods:The retrospective cohort study was conducted. The clinical data of 58 patients with recurrent hepatolithiasis who underwent laparoscopic biliary reoperation in the Chengdu Second People′s Hospital were collected. There were 33 males and 25 females, aged from 31 to 85 years, with an average age of 54 years. Thirty-one of 58 patients who underwent laparoscopic biliary reoperation using ligamentum teres hepatis approach were divided into the ligamentum teres hepatis group, and 27 patients who underwent laparoscopic biliary reoperation using regular anatomy and positioning were divided into the regular operation group. Observation indicators: (1) intraoperative situations; (2) postoperative recovery; (3) follow-up. Follow-up using telephone interview and outpatient examination was performed to detect the recurrence of bile duct stone up to August 2018. Doppler ultrasonography of biliary tract was performed once at 3, 6 and 12 months postoperatively and once at every 12 months after 1 year. Measurement data with normal distribution were represented as Mean±SD and comparison between groups was analyzed by the t test.Measurement data with skewed distribution were described as M (range) and comparison between groups was analyzed by rank sum test. Count data were analyzed using the four-grid table chi-square test or Fisher exact probability.
Results:(1) Intraoperative situations: all patients underwent successful laparoscopic biliary reoperation, without conversion to open surgery and perioperative death. During the intraoperative exploration, 7, 8, 16 patients in the ligamentum teres hepatis group and 5, 8, 14 patients in the regular operation group were respectively found peritoneal omental adhesions, hilar omental adhesions and hilar intestinal adhesions. The operation time and volume of intraoperative blood loss were (125±24)minutes, 40 mL(range,15-100 mL) in the ligamentum teres hepatis group and (150±36)minutes, 55 mL(range,20-350 mL) in the regular operation group, respectively, with statistically significant differences between the two groups (t=-3.162, Z=-2.768, P<0.05). The primary suture of bile duct, T-tube drainage and intraoperative stone removal were detected in 10, 21, 26 patients of ligamentum teres hepatis group and 9, 18, 23 patients of regular operation group, respectively, with no statistically significant difference between the two groups (χ²=0.008, 0.019, P>0.05). Postoperative residual biliary calculi were removed by choledochoscope through T-tube sinus in outpatient department after 8-week carrying T-tube. (2) Postoperative recovery: the time to initial anal exsufflation and duration of postoperative hospital stay were respectively (31±7)hours, (7.2±1.5)days in the ligamentum teres hepatis group and (35±10)hours, (7.1±1.3)days in the regular operation group, with no statistically significant difference between the two groups (t=-1.814, 0.036, P>0.05). (3) Follow-up: 5 of 58 patients were lost to follow-up, including 3 in the ligamentum teres hepatis group and 2 in the regular operation group. Fifty-three patients were followed up for 6-40 months, with a median follow-up time of 28 months. No recurrence of bile duct stone was found in the ligamentum teres hepatis group. One patient in the regular operation group had recurrence of common bile duct stones at 36 months postoperatively and underwent endoscopic sphincterotomy stone.
Conclusion:Laparoscopic biliary reoperation for patients with recurrence of hepatolithiasis is a safe and effective method, and it can also quickly determine the location of common bile duct, with advantages of less blood loss and shorter operation time.