Aust. N . Z . J . Surg.
941
1992,62,947-9.50
LAPAROSCOPY-GUIDED PERCUTANEOUS CHOLECYSTOLITHOTOMY: AN EVOLVING TECHNIQUE L. L. P. J. OOI,*P. 0. P. MACK,*M. K. Lrt
AND
L. K . YAP*
*Departments of Surgery, 'Urology and 'Obstetrics and Gynaecology, Singapore General Hospital, Singapore Gall-bladder conservation therapy has been evolving during the past decade. Popular techniques of conservative therapy are extracorporeal shock wave lithotripsy (ESWL) and medical dissolution therapy. The limitations of these procedures have prompted a search for alternative techniques, particularly in relation to percutaneous stone extraction. The cases of four patients with symptomatic gallstones who underwent percutaneous cholecystolithotomy under laparoscopic guidance are reported. The gall-bladder was punctured with a long needle and the tract dilated so that a nephroscope could be introduced. Three cases required stone fragmentation by an ultrasonic lithotripter before removal. Postoperative recovery was uneventful in all cases. Key words: cholecystostomy,cholelithiasis, lithotripsy, ultrasound.
Introduction The gold standard for effective treatment of cholelithiasis is cholecystectomy. However, in the past 20 years, various methods of alternative treatment with gall-bladder conservation, both interventional and non-interventional, have been attempted. Of interest is the wide range of gall-bladder-conserving therapies which have evolved and which are still in use. The more popular of these methods of conservation therapy are extracorporeal shock wave lithotripsy (ESWL) and medical dissolution therapy. However, these techniques are restricted by stone size, number and composition, post-lithotripsy cystic duct obstruction, lengthy treatment periods and side effects of chemolysis. To overcome these problems, and also to allow gall-bladder decompression at the same time, percutaneous stone extraction techniques have been considered. In 1988, Kellett et al. described a method of cholecystolithotomy to remove gallstones from functioning gall-bladders in a single stage, using ultrasound and fluoroscopy guidance.' Four case of gallstones being removed by a technique of percutaneous transperitoneal cholecystolithotomy using laparoscopy as a guide are described here.
Operative technique (Fig. 1) Pre-operative gallstone disease was confirmed by ultrasound and gall-bladder function was assessed Correspondence: Lucien 0 0 1 ,Depanment of Surgery, Singapore General Hospital, Singapore 0316. Accepted for publication 29 July 1992
by oral cholecystography in all cases. Only patients with symptomatic, uncomplicated gallstone disease and normal functioning gall-bladders, and those who desired to retain their gall-bladders were considered for the procedure. Under general anaesthesia in the supine position, the patient was draped as for laparoscopic cholecystectorny. Pneumoperitoneum was created by carbon dioxide insufflation through a Verres needle. A sub-umbilical stab incision was used to introduce the laparoscope and visualization on a video monitor facilitated co-ordination between surgeon and assistants. A long spinal needle was introduced through the right hypochondrium and passed under laparoscopic vision into the gall-bladder fundus which was held up by a pair of grasping forceps, inserted either through the biopsy channel of the laparoscope or through a separate port. A guide wire was then passed into the gall-bladder through the spinal needle, followed by graduated dilatation with fascia1 and telescopic metal dilators up to size 22F as is commonly done for percutaneous nephrolithotomy. Through the same port, a nephroscope was introduced into the gall-bladder for visualization of the mucosa and identification of stones. Stone removal was by grasping forceps introduced through the nephroscope, aided if necessary by ultrasonic lithotripsy water irrigation and suction. A 22F Jacques catheter was placed in the gall-bladder at the end of the procedure for drainage, anchored to skin by silk sutures, and left in for 10 days at which time a tubogram was performed to confirm complete stone removal.
OOIETAL.
948
Fig. 1. View through the laparoscope showing the gall-bladder being held up by two grasping forceps introduced through ports in the right hypochondrium (A, B, C). A spinal needle is introduced into the gall-bladderbetween the forceps (D), and this is followed by Teflon dilators (E) and metal dilators (F, G). The stone in the gall-bladder is then removed with ultrasonic lithotripsy and suction (H). A catheter is left in the gall-bladder through the cholecystostomy for postoperative drainage (I).
CASE I
A 57 year old Chinese woman with a 1 year history of' right hypochondria1 pain was diagnosed to have a solitary gallstone on ultrasound examination. She wanted to retain her gall-bladder in view of good gall-bladder function demonstrated on oral cholecystography . Laparoscopy was performed using the technique described and grasping forceps were introduced through the biopsy channel of the laparoscope to provide counter-traction. The guide wire was easily introduced into the gall-bladder. However during the process of telescopic dilatation, the gall-bladder was dissected in the seromuscular plane. This was, on retrospect, probably because of the inadequate counter-traction from the forceps introduced through the laparoscope port. Re-access into the gall-bladder lumen across the dissected wall was achieved with some difficulty. A large single cholesterol stone was found and required fragmentation by ultrasonic lithotripsy before
extraction. Operative time for the procedure was 3 h mainly because of the technical problem of wall dissection. Postoperative recovery was uneventful and a repeat oral cholecystogram 3 months later showed normal gall-bladder function. She was followed up for 21 months with no complaints. CASE 2
A 42 year old Indian woman was diagnosed with symptomatic gallstones. A technique similar to that for case 1 was used. Four small pigmented stones were easily extracted by forceps via the nephroscope. Operative time was l % h with no technical difficulties. She was followed up for 13 months with no problems. CASE 3
A 38 year old Chinese woman was diagnosed with symptomatic gallstone disease. She underwent a procedure similar to that described previously
LAPAROSCOPY-GUIDEDPERCUTANEOUS CHOLECYSTOLITHOTOMY
except for an additional port in the right hypochondrium to allow introduction of grasping forceps for counter-traction. This differed from the first two cases where the counter-tracting forceps were introduced through the biopsy channel of the laparoscopic viewing port in the sub-umbilical region. We found this modification to provide an easier puncture of the gall-bladder and dilatation of the tract, with only an extra small stab incision in the hypochondrium. Postoperative recovery was uneventful and she was followed up for 9 months. CASE 4
Using the same technique used in case 3 but with an additional port in the right hypochondrium making a total of two grasping ports (Fig. I), a 41 year old Chinese female underwent surgery with no technical difficulties. The additional port improved ease of procedure tremendously. She recovered well and is presently 5 months in follow-up.
Results A tubogram on the tenth postoperative day excluded biliary leak or retained stones in all four cases. There was no mortality. Possible complications of failure to cannulate the gall-bladder, bowel perforation, biliary peritonitis and gall-bladder dysfunction were not seen. Postoperative gall-bladder function was normal in all patients with follow-up time of 5 , 9, 13 and 21 months, confirmed by oral cholecystogram.
Discussion Gall-bladder conservation therapy has been controversial, the main objection being the possibility of stone recurrence. A review of the largest experience in open cholecystolithotomy during 36 years reported an overall stone recurrence rate of 34.6Y0.I Another review of 125 patients who had endoscopic removal of bile duct stones with stone-free gallbladders that were followed up, only 22% were found to have symptoms referrable to the biliary tree subsequently.2 These data suggest that gallbladder conservation therapy may be medically justifiable. Cholecystectomy has been the traditional method of treating gallstones and there has been an improvement in the form of laparoscopic cholecystectomy in recent years. In an Asian population, however, deeply rooted ethnic and cultural beliefs about the significance of the gal-bladder for good health have resulted in patients requesting gall-bladder conservation therapy. The techniques of gall-bladder conservation therapy currently popular in our institution have been ESWL and medical dissolution therapy.
949
However these techniques are limited by stone composition, size and number. Compared with ESWL and medical dissolution therapy percutaneous extraction methods allow stones of all varieties to be removed, with the added advantage of immediate gall-bladder d e c o m p r e ~ s i o n . ~ ~ ~ Cholecystostomy was first described in 1865’ and a combined open mini-cholecystostomy followed by delayed removal of stones through the cholecystostomy under radiological guidance was later described.6 Presently, it is usually performed by percutaneous puncture techniques using ultrasound or fluoroscopy guidance to drain the gall-bladder and remove stones in the same stage.’ Possible complications that may arise with radiologically guided percutaneous cholecystolithotomy include procedural failure, bile peritonitis and bowel pe rf~ra tion.~,~.’ We describe here the technique of laparoscopyguided endoscopic cholecystolithotomy as a surgical variant of gall-bladder conservation therapy which allows visualization and direct puncture of the gallbladder. This enabled cannulation in all four patients with no complications, except for some difficulty in the first case of inappropriate counter-traction. Laparoscopy also allowed for suction removal of bile spilled, reducing bile peritonitis. Direct gallbladder luminal visualization with a nephroscope allowed lithotripsy, ensured complete stone removal and excluded the possibility of missing a gallbladder carcinoma in the conserved gall-bladder. All four patients had a Jacques catheter left indwelling for 10 days, anchored to the skin with silk sutures. There was no morbidity as a result of the cholecystostomy tube and all wounds closed almost immediately after removal of the tube. Patients who are educated have in fact been sent home in some centres and told to return for tubogram and removal on the tenth day to reduce the costs of hospital stay. With improvements and advances in laparoscopic instrumentation, we are presently studying the possibility of using endostapler devices to close off the cholecystostomy at the end of the procedure, obviating the need to leave a drain. In one study, the use of metal clips and fibrin glue have been tried.8 With our limited experience in this procedure, we feel that it would be suitable in only a select group of patients who strongly desire to conserve a functioning gall-bladder. It is unlikely to be suitable for gangrenous gall-bladders because of the possibility of tearing the friable gall-bladder wall during mechanical grasping and dilatation of the tract. In such situations, a percutaneous ultrasoundguided needle cholecystostomy under local anaesthesia, followed at a later date by actual stone removal, has been practised in our centre. In the majority of our cases, laparoscopic cholecystectomy is the mainstay of treatment.
950
001E T A L .
Laparoscopy-guided percutaneous cholecystostomy forms a complementary treatment modality in a small proportion of patients who desire gall-bladder conservation therapy for cultural reasons.
4.
References
5.
1. KELLETT M. J . , WICKHAM J . E. A. & RUSSELL R. C. G. (1988) Percutaneous cholecystolithotomy. Br. Med. J . 296, 453-5. 2. COITONP. B. (1988) Endoscopic management of gallbladder stones. In: Surgery of the Liver and Biliury Tract (Ed. L. H . Blumgart), pp. 569-73. Churchill Livingstone, Edinburgh. 3. MALONE D. E. & BURHENNE H . J . (1989) Advantages
6. 7. 8.
and disadvantages of the newer ‘interventional’ procedures for the treatment of cholecystolithiasis. Hepatogustroenterol. 36, 3 17-26. THISTLE J. L. (1989) Pros and cons of the non-surgical treatments for gallbladder stones. Heputogastroenterol. 36, 327-9. SPARKMAN R. S. (1967) Bobbs centennial: the first cholecystostomy. Surgery 61, 965-71. BURHENNE H . J . & STOLLER J . L. (1985) Minicholecystostomy and radiologic stone extraction in high risk cholelithiasis patients. Am. J . Surg. 149, 632-5. M., HRUBY W., STACKL W. & ARMBRUSTER MARBERCER C. (1989) Percutaneous cholecysto-lithotripsy: lessons learned. World. J , Urol. 7 , 122-8. FRIMBERCER E. (1989) Operative laparoscopy and cholecystostomy. Endoscopy 21, 367-72.
941
1992,62,947-9.50
LAPAROSCOPY-GUIDED PERCUTANEOUS CHOLECYSTOLITHOTOMY: AN EVOLVING TECHNIQUE L. L. P. J. OOI,*P. 0. P. MACK,*M. K. Lrt
AND
L. K . YAP*
*Departments of Surgery, 'Urology and 'Obstetrics and Gynaecology, Singapore General Hospital, Singapore Gall-bladder conservation therapy has been evolving during the past decade. Popular techniques of conservative therapy are extracorporeal shock wave lithotripsy (ESWL) and medical dissolution therapy. The limitations of these procedures have prompted a search for alternative techniques, particularly in relation to percutaneous stone extraction. The cases of four patients with symptomatic gallstones who underwent percutaneous cholecystolithotomy under laparoscopic guidance are reported. The gall-bladder was punctured with a long needle and the tract dilated so that a nephroscope could be introduced. Three cases required stone fragmentation by an ultrasonic lithotripter before removal. Postoperative recovery was uneventful in all cases. Key words: cholecystostomy,cholelithiasis, lithotripsy, ultrasound.
Introduction The gold standard for effective treatment of cholelithiasis is cholecystectomy. However, in the past 20 years, various methods of alternative treatment with gall-bladder conservation, both interventional and non-interventional, have been attempted. Of interest is the wide range of gall-bladder-conserving therapies which have evolved and which are still in use. The more popular of these methods of conservation therapy are extracorporeal shock wave lithotripsy (ESWL) and medical dissolution therapy. However, these techniques are restricted by stone size, number and composition, post-lithotripsy cystic duct obstruction, lengthy treatment periods and side effects of chemolysis. To overcome these problems, and also to allow gall-bladder decompression at the same time, percutaneous stone extraction techniques have been considered. In 1988, Kellett et al. described a method of cholecystolithotomy to remove gallstones from functioning gall-bladders in a single stage, using ultrasound and fluoroscopy guidance.' Four case of gallstones being removed by a technique of percutaneous transperitoneal cholecystolithotomy using laparoscopy as a guide are described here.
Operative technique (Fig. 1) Pre-operative gallstone disease was confirmed by ultrasound and gall-bladder function was assessed Correspondence: Lucien 0 0 1 ,Depanment of Surgery, Singapore General Hospital, Singapore 0316. Accepted for publication 29 July 1992
by oral cholecystography in all cases. Only patients with symptomatic, uncomplicated gallstone disease and normal functioning gall-bladders, and those who desired to retain their gall-bladders were considered for the procedure. Under general anaesthesia in the supine position, the patient was draped as for laparoscopic cholecystectorny. Pneumoperitoneum was created by carbon dioxide insufflation through a Verres needle. A sub-umbilical stab incision was used to introduce the laparoscope and visualization on a video monitor facilitated co-ordination between surgeon and assistants. A long spinal needle was introduced through the right hypochondrium and passed under laparoscopic vision into the gall-bladder fundus which was held up by a pair of grasping forceps, inserted either through the biopsy channel of the laparoscope or through a separate port. A guide wire was then passed into the gall-bladder through the spinal needle, followed by graduated dilatation with fascia1 and telescopic metal dilators up to size 22F as is commonly done for percutaneous nephrolithotomy. Through the same port, a nephroscope was introduced into the gall-bladder for visualization of the mucosa and identification of stones. Stone removal was by grasping forceps introduced through the nephroscope, aided if necessary by ultrasonic lithotripsy water irrigation and suction. A 22F Jacques catheter was placed in the gall-bladder at the end of the procedure for drainage, anchored to skin by silk sutures, and left in for 10 days at which time a tubogram was performed to confirm complete stone removal.
OOIETAL.
948
Fig. 1. View through the laparoscope showing the gall-bladder being held up by two grasping forceps introduced through ports in the right hypochondrium (A, B, C). A spinal needle is introduced into the gall-bladderbetween the forceps (D), and this is followed by Teflon dilators (E) and metal dilators (F, G). The stone in the gall-bladder is then removed with ultrasonic lithotripsy and suction (H). A catheter is left in the gall-bladder through the cholecystostomy for postoperative drainage (I).
CASE I
A 57 year old Chinese woman with a 1 year history of' right hypochondria1 pain was diagnosed to have a solitary gallstone on ultrasound examination. She wanted to retain her gall-bladder in view of good gall-bladder function demonstrated on oral cholecystography . Laparoscopy was performed using the technique described and grasping forceps were introduced through the biopsy channel of the laparoscope to provide counter-traction. The guide wire was easily introduced into the gall-bladder. However during the process of telescopic dilatation, the gall-bladder was dissected in the seromuscular plane. This was, on retrospect, probably because of the inadequate counter-traction from the forceps introduced through the laparoscope port. Re-access into the gall-bladder lumen across the dissected wall was achieved with some difficulty. A large single cholesterol stone was found and required fragmentation by ultrasonic lithotripsy before
extraction. Operative time for the procedure was 3 h mainly because of the technical problem of wall dissection. Postoperative recovery was uneventful and a repeat oral cholecystogram 3 months later showed normal gall-bladder function. She was followed up for 21 months with no complaints. CASE 2
A 42 year old Indian woman was diagnosed with symptomatic gallstones. A technique similar to that for case 1 was used. Four small pigmented stones were easily extracted by forceps via the nephroscope. Operative time was l % h with no technical difficulties. She was followed up for 13 months with no problems. CASE 3
A 38 year old Chinese woman was diagnosed with symptomatic gallstone disease. She underwent a procedure similar to that described previously
LAPAROSCOPY-GUIDEDPERCUTANEOUS CHOLECYSTOLITHOTOMY
except for an additional port in the right hypochondrium to allow introduction of grasping forceps for counter-traction. This differed from the first two cases where the counter-tracting forceps were introduced through the biopsy channel of the laparoscopic viewing port in the sub-umbilical region. We found this modification to provide an easier puncture of the gall-bladder and dilatation of the tract, with only an extra small stab incision in the hypochondrium. Postoperative recovery was uneventful and she was followed up for 9 months. CASE 4
Using the same technique used in case 3 but with an additional port in the right hypochondrium making a total of two grasping ports (Fig. I), a 41 year old Chinese female underwent surgery with no technical difficulties. The additional port improved ease of procedure tremendously. She recovered well and is presently 5 months in follow-up.
Results A tubogram on the tenth postoperative day excluded biliary leak or retained stones in all four cases. There was no mortality. Possible complications of failure to cannulate the gall-bladder, bowel perforation, biliary peritonitis and gall-bladder dysfunction were not seen. Postoperative gall-bladder function was normal in all patients with follow-up time of 5 , 9, 13 and 21 months, confirmed by oral cholecystogram.
Discussion Gall-bladder conservation therapy has been controversial, the main objection being the possibility of stone recurrence. A review of the largest experience in open cholecystolithotomy during 36 years reported an overall stone recurrence rate of 34.6Y0.I Another review of 125 patients who had endoscopic removal of bile duct stones with stone-free gallbladders that were followed up, only 22% were found to have symptoms referrable to the biliary tree subsequently.2 These data suggest that gallbladder conservation therapy may be medically justifiable. Cholecystectomy has been the traditional method of treating gallstones and there has been an improvement in the form of laparoscopic cholecystectomy in recent years. In an Asian population, however, deeply rooted ethnic and cultural beliefs about the significance of the gal-bladder for good health have resulted in patients requesting gall-bladder conservation therapy. The techniques of gall-bladder conservation therapy currently popular in our institution have been ESWL and medical dissolution therapy.
949
However these techniques are limited by stone composition, size and number. Compared with ESWL and medical dissolution therapy percutaneous extraction methods allow stones of all varieties to be removed, with the added advantage of immediate gall-bladder d e c o m p r e ~ s i o n . ~ ~ ~ Cholecystostomy was first described in 1865’ and a combined open mini-cholecystostomy followed by delayed removal of stones through the cholecystostomy under radiological guidance was later described.6 Presently, it is usually performed by percutaneous puncture techniques using ultrasound or fluoroscopy guidance to drain the gall-bladder and remove stones in the same stage.’ Possible complications that may arise with radiologically guided percutaneous cholecystolithotomy include procedural failure, bile peritonitis and bowel pe rf~ra tion.~,~.’ We describe here the technique of laparoscopyguided endoscopic cholecystolithotomy as a surgical variant of gall-bladder conservation therapy which allows visualization and direct puncture of the gallbladder. This enabled cannulation in all four patients with no complications, except for some difficulty in the first case of inappropriate counter-traction. Laparoscopy also allowed for suction removal of bile spilled, reducing bile peritonitis. Direct gallbladder luminal visualization with a nephroscope allowed lithotripsy, ensured complete stone removal and excluded the possibility of missing a gallbladder carcinoma in the conserved gall-bladder. All four patients had a Jacques catheter left indwelling for 10 days, anchored to the skin with silk sutures. There was no morbidity as a result of the cholecystostomy tube and all wounds closed almost immediately after removal of the tube. Patients who are educated have in fact been sent home in some centres and told to return for tubogram and removal on the tenth day to reduce the costs of hospital stay. With improvements and advances in laparoscopic instrumentation, we are presently studying the possibility of using endostapler devices to close off the cholecystostomy at the end of the procedure, obviating the need to leave a drain. In one study, the use of metal clips and fibrin glue have been tried.8 With our limited experience in this procedure, we feel that it would be suitable in only a select group of patients who strongly desire to conserve a functioning gall-bladder. It is unlikely to be suitable for gangrenous gall-bladders because of the possibility of tearing the friable gall-bladder wall during mechanical grasping and dilatation of the tract. In such situations, a percutaneous ultrasoundguided needle cholecystostomy under local anaesthesia, followed at a later date by actual stone removal, has been practised in our centre. In the majority of our cases, laparoscopic cholecystectomy is the mainstay of treatment.
950
001E T A L .
Laparoscopy-guided percutaneous cholecystostomy forms a complementary treatment modality in a small proportion of patients who desire gall-bladder conservation therapy for cultural reasons.
4.
References
5.
1. KELLETT M. J . , WICKHAM J . E. A. & RUSSELL R. C. G. (1988) Percutaneous cholecystolithotomy. Br. Med. J . 296, 453-5. 2. COITONP. B. (1988) Endoscopic management of gallbladder stones. In: Surgery of the Liver and Biliury Tract (Ed. L. H . Blumgart), pp. 569-73. Churchill Livingstone, Edinburgh. 3. MALONE D. E. & BURHENNE H . J . (1989) Advantages
6. 7. 8.
and disadvantages of the newer ‘interventional’ procedures for the treatment of cholecystolithiasis. Hepatogustroenterol. 36, 3 17-26. THISTLE J. L. (1989) Pros and cons of the non-surgical treatments for gallbladder stones. Heputogastroenterol. 36, 327-9. SPARKMAN R. S. (1967) Bobbs centennial: the first cholecystostomy. Surgery 61, 965-71. BURHENNE H . J . & STOLLER J . L. (1985) Minicholecystostomy and radiologic stone extraction in high risk cholelithiasis patients. Am. J . Surg. 149, 632-5. M., HRUBY W., STACKL W. & ARMBRUSTER MARBERCER C. (1989) Percutaneous cholecysto-lithotripsy: lessons learned. World. J , Urol. 7 , 122-8. FRIMBERCER E. (1989) Operative laparoscopy and cholecystostomy. Endoscopy 21, 367-72.
