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8 Application ofEndoscopic Techniques inBiliary Tract Surgery
also for choledochoscopy and treatment through postoperative T-tube sinus, which has undoubtedly expanded the scope
of choledochoscopy application. Therefore, the ber choledochoscopy invented by Shore is a milestone in the history
of choledochoscopy. In 1971, Professor Kenji Chang of
Japan Medical University formed a committee for the development of a choledochoberscope, and Matsuda
Manufacturing Institute took the lead in the trial production.
Ten years later, Japan became the main and even the only
exporter of beroptic choledochoscopes and developed
various types of beroptic choledochoscope. The application
of beroptic choledochoscopy in China began in 1978. The
First Clinical Hospital of Beijing Medical University rst
published the clinical application of this technique in China.
Although China started relatively late, the large number of
cases in China coupled with centers of excellence has
provided an environment with highly skilled and experienced
practitioners.
Choledochoscopy is mainly used for endoscopic exami-
nation of pancreaticobiliary duct and endoscopic surgery. It
can be divided into rigid choledochoscopy, soft choledochoscopy, ber choledochoscopy, electronic choledochoscopy, direct choledochoscopy, and peroral choledochoscopy.
According to the technical classication of choledochoscopy, it can be divided into (a) intraoperative choledochoscopy, routine intraoperative choledochoscopy, laparoscopic
choledochoscopy, robotic choledochoscopy; (b) postoperative choledochoscopy, which enters the biliary tract through
the sinus tract of a T-tube (T-shaped drainage tube); through
the jejunal blind loop after biliary anastomosis; through the
cholecystostomy drainage sinus; (c) preoperative choledochoscopy, namely, percutaneous transhepatic choledochoscopy; and (d) transoral choledochoscopy, namely, duodenal
choledochoscopy.
175
Fig. 8.1 Initial puncture and catheterization
8.3.1 Preoperative Application
Percutaneous transhepatic cholangioscopy (PTCS) refers to
percutaneous transhepatic cholangiopuncture drainage
(PTCD) followed by PTCD sinus dilatation. When the sinus
is expanded to accommodate choledochoscope into the biliary tract, ber choledochoscopy and treatment are performed
(Figs.8.1 and 8.2).
Indications
• Obstructive Jaundice For patients with suspected hepatobiliary duct dilatation via examination such as PTC,
B-ultrasound, ERCP, and CT. The critically ill patients
can be treated with PTCD bile duct decompression and
dissection rst, and then PTCS to conrm the location
and cause of obstruction.
Fig. 8.2 Gradually replace to PTCD tube with a thicker diameter
176
Z. Tang and C. Fang
• Advanced Cholangiocarcinoma It can be treated with
PTCS palliative catheterization and drainage,
chemotherapy and laser therapy, or radionuclide probe
implantation.
• Complex Hepatolithiasis
• Elderly Patients with Bile Duct Stones who Cannot
Tolerate Surgery Stones can be removed by PTCS
lithotripsy, or combined with perfusion lithotripsy,
oscillatory lithotripsy, etc.
• Dilation of Benign Biliary Strictures Traumatic stricture and stricture of cholangioenterostomy.
• Intrahepatic Bile Duct Ascariasis
• Bile Duct Malformation Especially for elderly patients
with high-risk obstructive jaundice and patients with
advanced biliary tract tumors, the choledochoscope has
played a positive role in relieving biliary obstruction and
related symptoms, and sometimes even become the main
treatment for this disease.
Contraindication
• Patients with no dilatation of intrahepatic bile duct.
• Abnormal blood coagulation and platelets below 80,000/
3
mm
.
• Liver or kidney failure.
• Liver diseases, such as portal hypertension with liver cirrhosis, hepatic hemangioma.
• Heart failure; patients unwilling to cooperate.
• Preoperative diagnosis is not consistent with intraoperative diagnosis.
• When there is a small number of intrahepatic bile duct
stones, and when surgical removal is difcult,
intraoperative choledochoscope can be carried out; the
choledochoscope can also be used to determine whether
the stones are completely removed.
• Inspection of omitted bile duct stones after
cholecystostomy.
• Removal of stones in laparoscopic choledocholithotomy.
Advantages
• Reduced the incidence of residual stones after biliary tract
surgery.
• Intraoperative cholangioscopy is helpful for the diagnosis
of the lesion and provides the basis for the choice of surgical methods.
Disadvantages
• Intraoperative choledochoscopy is not convenient, and it
is not as easy as postoperative choledochoscopy in stone
removal.
• Prolonged exposure of the wound; salt and bile spillage
can easily contaminate the abdominal cavity.
• Laparoscopic choledocholithotomy with beroptic choledochoscope can easily damage the choledochoscope.
Complications
• Biliary Hemorrhage It usually occurs in patients with
abnormal coagulation function, when liver parenchyma is
punctured or sinus tract is dilated, or when larger stones
are removed.
• Bile Leakage or Biliary Peritonitis It usually occurs
when puncture or replacement of a drainage tube is too
early or when a drainage tube falls off.
• Fever Transient. The drainage tube should be kept unobstructed and antibiotics should be used if necessary.
• Nausea and Vomiting It usually occurs during the sinus
dilatation or during the examination and stone removal
process, mainly caused by stimulation from injecting
water too quickly.
• Cardiovascular Accident
8.3.2 Intraoperative Application
Indications
• Unknown preoperative diagnosis of biliary diseases.
Suspected biliary tract space-occupying lesions need
denite diagnosis during operation. If there is stenosis of
the biliary tract, biopsies are required for the selection of
surgical procedures.
8.3.3 Postoperative Application
Indications
• Known or suspected residual biliary stones.
• Biliary tumor or suspected biliary space-occupying
lesions need to be conrmed by pathology.
• Advanced choledochal tumors with obstructive jaundice
require choledochoscope treatment.
• Biliary tract malformations or stenosis.
• Biliary ascariasis.
• Biliary bleeding.
• Foreign body in the biliary tract.
• Selective cholangiography.
• Sclerosing cholangitis (the only reliable diagnostic method).
• Study on the dynamics of biliary tract.
Contraindication
• Patients with apparent coagulation abnormalities.
• Patients with severe cardiopulmonary dysfunction.
• Patients with fever caused by issues other than biliary
tract disease.
Complications
• Fever It can occur after choledochoberscope examination, usually at about 38 °C and usually it is transient.
8 Application ofEndoscopic Techniques inBiliary Tract Surgery
177
Fever can be caused by the following factors, including
improper disinfection of instruments, not strictly following aseptic technique, or excessive increase in pressure
caused by physiological saline ushing into the biliary
tree. Turbid bile after infection can be observed in the
drainage tube. Usually, fever does not require special
treatment; only with persistent bile drainage will fever
subside. Intravenous antibiotics for severe infections are
required.
• Sinus Perforation When a bercholedochoscope is
inserted into the sinus and pushed forward and does not
enter the biliary tract. Instead, it enters a “cavity” without
red granulation tissue as the wall, with a dimly lit space.
When the mirror is continuously pushed forward, the pink
appearance of the small intestine can be observed. At the
same time, the sinus outow is a reddish liquid, without
bile, which conrms that the choledochoscope entered the
abdominal cavity through the perforated sinus. Sinus
perforation is often caused by premature postoperative
beroptic choledochoscopy, rough operation of the
choledochoscope, and blind endoscopy without sinus
orice. Therefore, bercholedochoscopy or lithotomy
must be performed at least 6 weeks after surgery, not
beforehand. If the patient is weak and recovers slowly, the
stone removal should be postponed appropriately because
the sinus will not be strong enough. Otherwise, an
excessively thin sinus tract can be easily perforated.
Fiberoptic choledochoscopes should be operated gently.
Only when the small hole in the sinus tract is observed
can the mirror be slowly inserted, which is important to
avoid perforating the sinus.
• Sinus fracture When larger stones are removed by
bercholedochoscope, the small opening of the sinus
may not be found when the choledochoscope is reinserted so that the choledochoscope cannot be inserted
into the biliary tract and enters the abdominal cavity, and
the small pink intestine appears in the eld of vision. In
the course of pulling the large stone out of the sinus, the
surgeon exerted too much force, and the assistant did not
press the skin around the ostium with his hand. Other
issues such as early stone removal, old and weak
patients, or a weak sinus tract, can lead to sinus rupture.
The stone removal time should not be too early. When
the surgeon pulls out a large stone, the assistant should
press the skin around the sinus ostium to prevent the
sinus from being broken.
• Hemobilia Fiberoptic choledochoscopy and lithotomy
can reveal hyperemia and edema of the bile duct mucosa,
erosion, and even ulceration. The diseased bile duct has
blood clots, a reddish uid lls the eld of vision, and
bleeds are visible after rinsing, similar to a uttering red
ribbon. Situations which may precipitate this condition
include: Cholangitis in the bile duct due to stones, or even
ulcers in the mucus membrane of the duct; pulling out
larger stones may lead to varying degrees of bleeding,
poor liver function, and abnormal clotting times.
Prevention: (a) the operation of bercholedochoscope
should be gentle; (b) the patient’s liver function should be
treated and protected with antibiotics, and stones should
not be taken until the patient’s biliary tract infection has
subsided and liver function is normal; (c) the vast majority
of patients with biliary tract hemorrhage do not require
special treatment, and hemostasis can be obtained by
irrigation of the bile duct with a solution made by adding
0.5 mg of adrenaline to 500 ml of normal saline. If
hemostasis fails, microwaves can be used to stop bleeding
delivered with a beroptic choledochoscope.
• Tear in the bile duct Fibercholedochoscopy shows a s-
sure at the opening of the diseased bile duct, and bleeding
and blood clots in the biliary ssure. Possible reasons
include: (a) The bile duct opening is narrow; when larger
stones in the dilated bile duct are removed, a rough operation may lead to tear in the bile duct; (b) in some cases,
the conventional operation of advancing while observing
directly under beroptic choledochoscope is neglected;
severe complication caused by a bile duct tear may also
occur if the operation of brocholedochoscopy is excessively dependent on X-ray uoroscopy. Prevention: The
operation of the brocholedochoscopy should be gentle,
without too much force, and should be advanced while
observing the lens; beroptic choledochoscopy must be
stopped once the bile duct tear occurs, and biliary bleeding can be prevented by normal saline ush (500ml of
saline +0.5ml of adrenaline); T-tube drainage should be
replaced, and intravenous antibiotics should be given for
several days. After 2 ~ 3 weeks, brocholedochoscopy
can be performed.
• Diarrhea After choledochoberscope examination, diarrhea, watery stool, no mucus, and no blood observed.
Possible cause: the perfusion of physiological saline
during choledochoberscopy was excessive (more than
3000ml). Prevention: during each choledochoberscope
examination, the physiological saline should not exceed
3000ml; no special treatment is needed for diarrhea.
• Acute Pancreatitis Symptoms such as abdominal pain,
fever, abdominal distension occur. Blood and urine amylase levels increase. Possible reasons: when stones are
taken through the choledochoscopy, especially the
stones embedded in the ventral ampulla of Vater, local
injury may occur, leading to inammation, edema, and
pancreatic juice obstruction, which may cause pancreatitis. Prevention: actions to mitigate and keep occurrence to a minimum include: assuring appropriate
cleaning, disinfection, and aseptic technique of the
device, careful control of saline infusion pressure to prevent excessive pressure, review of the stone removal
178
Z. Tang and C. Fang
procedure. Prevention: Strengthen the disinfection and
aseptic technique of the device. The pressure of saline
infusion should not be excessive. Check the stone
removal operation. If acute pancreatitis arises during the
procedure, keep the T tube circulated smoothly,
strengthen the antibiotics, relieve pain, relieve spasm,
and inhibit pancreatic secretion, and most of them can
be cured.
• Nausea and Vomiting Symptoms of nausea and vomiting
related to the treatment of beroptic choledochoscopy can
occur after surgery. Possible reasons: the stimulation of
intrahepatic bile duct or the opening of the dilated Oddi
sphincter by beroptic choledochoscopy; excessive
pressure of saline infusion. Prevention: The treatment of
ber choledochoscopy should be gentle, and the pressure
of saline should not be too high. When symptoms of
nausea and vomiting occur, intramuscular injection of
metoclopramide can be performed.
8.4 Capsule Endoscopy
Capsule endoscopy, also known as wireless endoscopy, is a
high-tech product developed and produced in Israel around
the turn of the century. The capsule, which contains a tiny
camera, light source, battery, and transmitter, is similar in
shape to a large vitamin pill. After a patient swallows the
capsule, a tiny wireless camera inside moves naturally
through the gastrointestinal tract taking thousands of pictures
that are transmitted to a recording device carried by the
patient. The imaging data of the small intestine can be
obtained without pain. Capsule endoscopy is prominent in
the diagnosis of unknown gastrointestinal bleeding and small
intestine disease, so it is a great advance both technically and
clinically. Also, the advantages of simple operation, no
complication, and no need for hospitalization are undoubtedly
a signicant progress in the history of diagnosing small
intestine diseases. Capsule endoscopy will replace the
application of propulsive enteroscopy in the diagnosis of
small intestine diseases and become the rst choice for
patients with suspected small intestine disease after gastroscopy and colonoscopy (Table8.1).
The main complication of capsule endoscopy is the
risk that the capsule does not pass through the intestine
smoothly. Capsule staying in the digestive tract for
2weeks or more is dened as capsule retention, requiring
medication, endoscopic, or surgical intervention. The
incidence of retention is associated with underlying diseases, including Crohn’s disease, intestinal stenosis
caused by nonsteroidal anti-inammatory drugs (NSAID),
radiation enteritis, and small bowel tumors. Even in the
healthy small intestine, the occurrence of retention cannot
be avoided entirely.
Table 8.1 Indications and contraindications of capsule endoscopy
Indications Contraindications
Gastrointestinal bleeding of
unknown origin
Hypoferric anemia Clinical or radiographic features of
Crohn’s disease Extensive and acute Crohn’s disease
Intestinal tumor Intestinal pseudo-obstruction
NSAID-induced enteropathy Relative contraindication
Portal hypertensive
enteropathy
Celiac disease Dysphagia
Hereditary polyposis
syndrome
Functional abdominal pain Pregnancy
Absolute contraindication
ileus
with obstruction
Cardiac implantable electronic
devices such as pacemakers
A history of prior abdominal or
pelvic surgery
Extensive diverticulosis
8.5 Laparoscope
In April 1991, Gou Zuwu of the Second People’s Hospital of
Qujing, Yunnan Province, successfully performed the rst
laparoscopic cholecystectomy independently in China,
marking the beginning of the development of laparoscopic
surgery in mainland China. The laparoscopic technique is
most suitable for the treatment of certain benign diseases and
early tumors, such as fenestration of hepatic cysts, resection
of large intestinal tumors, repair of the gastric fold of
esophageal hiatus hernia, repair of abdominal hernia,
removal of gastric leiomyoma, gastrointestinal cancer,
gastrointestinal perforation repair, the release of adhesive
intestinal obstruction; moreover, diseases such as thyroid,
breast, lower extremity varicose veins, various causes of
hypersplenism splenectomy, and other diseases can be
treated with minimally invasive treatment, and the effect is
signicant. In recent years, laparoscopic surgery is
progressing to a higher eld, and the indications for surgery
are expanding to the treatment of diseases in various systems.
Trauma is diminishing. Surgery has experienced the transition from traditional laparotomy to minimally invasive
laparoscopic surgery. Now, it is developing from porous
laparoscopic surgery to single-port laparoscopic surgery
(SPLS). At present, the primary single-port surgery is
transumbilical single-port laparoscopic surgery. Natural
orice transumbilical surgery (NOTUS) is a transumbilical
punctured tube with multiple operating channels. The
operation is performed by placing the surgical instrument
through the operation channel, and the specimen is removed
through the umbilicus. The surgical incision is located in the
umbilical cord. The skin fold of the umbilical cord can cover
the incision and achieve a satisfactory cosmetic effect. In the
age of scientic and technological explosion, the single-port
laparoscopic technique brought about by the leap of surgical
technology is still in the exploratory stage. However, it has
8 Application ofEndoscopic Techniques inBiliary Tract Surgery
179
denite advantages: scarless, enhanced cosmetic effect, and
reduced incision to reduce postoperative pain. Faster
recovery reduces the chance of herniation and infection.
8.6 Endoscopic Ultrasound
Endoscopic ultrasound (EUS) is a combination of endoscopy
and ultrasound for gastrointestinal tract examination. The
miniature high-frequency ultrasonic probe is placed at the
top of the endoscope. When the endoscope is inserted into
the body cavity, the pathological changes of digestive tract
mucosa are observed directly through the endoscope. The
real-time scanning of EUS examination can be used to obtain
the histological features of the gastrointestinal hierarchy and
surrounding structures; thus, further improving the diagnostic
level of endoscopy and ultrasound. The exploration of biliary
tract diseases can be completed by longitudinal EUS and
circumferential EUS. Longitudinal EUS is particularly
suitable for exploring the relationship between the distal
common bile duct and ampulla, and for judging the nature of
pancreatic masses. Based on endoscopic retrograde
cholangiography (ERC), intraductal ultrasonography (IDUS)
is performed with small probe ultrasound, which has some
advantages in detecting hepatic hilar cholangiopathy. The
ne-needle puncture (endoscopic ultrasound-guided neneedle aspiration, EUS-FNA) guided by longitudinal EUS
can be used to obtain the cellular and/or histopathological
diagnosis of biliary space-occupying lesions. The diagnostic
sensitivity and accuracy are superior to traditional methods.
The application of a series of new functions and techniques
such as harmonic contrast ultrasound elastic imaging and 3D
ultrasound imaging will further improve the role of EUS in
the diagnosis of benign and malignant biliary tract diseases.
Under EUS, malignant pancreatic tumors appear as
hypoechoic areas with blurred borders, scattered
calcications and liquefaction areas, compression of the
peritoneal pancreatic duct, or interruption of the wall echoes
or solid echoes in the pancreatic duct, and dilatation of the
pancreatic duct at the distal end of the tumor. When the
adjacent organs are inltrated, the serous layer of adjacent
organs is broken; the echo layer of the wall of the vessel is
interrupted when the blood vessel is inltrated. When the
tube is inltrated, the dilated bile duct is interrupted, and the
lymph nodes around the pancreas are enlarged.
EUS-FNA can provide a relatively accurate pathological
and cytological diagnoses, avoiding the use of traumatic
tissue diagnostics such as diagnostic laparoscopy. The latest
linear scan endoscopic ultrasonography (LSE) can be used
for real-time ultrasound-guided puncture biopsy with a
19-22G puncture needle to obtain a more rapid and accurate
cytological diagnosis. In addition to cytological specimens,
histopathological specimens can be obtained by using cutting
needles with larger inner diameter. The clinical observation
showed that the sensitivity and specicity of EUS-FNA in
the diagnosis of solid pancreatic tumor were very high, and
the operation was safe. The complication rate was less than
1%. For some patients, enhanced scanning or elastography
guided by endoscopic ultrasound can also be used to conrm
the diagnosis.
8.6.1 EUS-Guided Biliary Drainage through
theTransduodenal Route
Biliary drainage under ERCP is an established technique for
biliary obstruction secondary to pancreatic head
malignancies. However, if ERCP fails, EUS-guided biliary
drainage (EUS-BD) through the transduodenal approach can
be used as an alternative drainage technique (Figs.8.3, 8.4,
and 8.5).
8.6.2 EUS-Guided Radioactive Seed
Implantation inPancreatic Cancer
The parameters of an iodine-125 seed were as follows: activity 0.40~ 0.50 mCi, with a half-life of 60.1 days, a mean
photon energy of 27–35keV γ-ray, and penetration distance
in the human tissue of only 1.7cm. The implanted iodine-125
seeds can generate a high dose within the tumor tissue, which
Fig. 8.3 MRCP suggests dilated bile duct
180
Fig. 8.4 Endoscopic ultrasonography-guided puncture
Z. Tang and C. Fang
8.7 3D Visualization-Assisted Endoscopic Technology
In 2001, the 3D visualization system became used to clearly
show the location, the shape, the size, and the number of the
stones; the spatial position and extent of the bile duct stenosis
are also represented accurately. 3D-assisted endoscopy is of
great signicance for the classication, diagnosis, and
surgical guidance of hepatolithiasis. The combination of 3D
visualization systems and traditional endoscopic techniques
in biliary surgical diseases, especially biliary calculi, has
fully utilized the advantages of precise diagnosis and
treatment and minimally invasive treatment, and effectively
improved the therapeutic effect.
Percutaneous transhepatic choledochoscopy (PTCS): The
sinus tract is dilated once a week after percutaneous
transhepatic biliary drainage (PTBD), and then expanded to
16F in two weeks in order to perform ber choledochoscopy.
Extraction of stone through dilated sinus tract is a method
with a long cycle and high frequency of dilatation, and
patients experience a higher incidence of bleeding, bile
leakage, cholangitis, and peritonitis, postoperatively. It has
been reported in the literature that the complication rates
following PTCS range from 9% to 26% (Weber etal. 2009;
Li et al. 2015; Inamdar et al. 2016). By preoperative
MI-3DVS, the time of percutaneous transhepatic biliary
drainage stula for percutaneous transhepatic cholangioscopic lithotomy (PTCSL) can be optimized. Animal studies
have shown that the wall of percutaneous hepatic stula,
intramural vascular embolization, brous tissue hyperplasia,
and adhesion between the hepatic surface around the stula
and the thoracic and abdominal wall are formed at 5~7days
after PTCD; at this time, lithotripsy after percutaneous
hepatic dilatation (Figs.8.6, 8.7, 8.8, and 8.9) is relatively
Fig. 8.5 Endoscopic ultrasonography-guided drainage
is sufcient to kill tumor cells and achieve good clinical
effect in the treatment of advanced pancreatic cancer.
Compared with traditional surgical implantation of radioactive particles for pancreatic cancer, EUS-guided iodine
125
I
implantation in pancreatic cancer appears to be a safer and
more effective minimally invasive technique for the management of pancreatic cancer.
Fig. 8.6 B-mode ultrasonography positioning
8 Application ofEndoscopic Techniques inBiliary Tract Surgery
Fig. 8.7 Dilated bile duct puncture and bile extract
181
Fig. 8.9 Indwelling of 8F drainage tube
8.8 Endoscopic Diagnosis
andManagement ofHepatobiliary
andPancreatic Diseases
Fig. 8.8 Dilated sinus tract
safe. Because intrahepatic cholelithiasis is often accompanied by various degrees of obstruction, the pressure in the
dilated bile duct is high. The drainage of bile reduces the
internal pressure of bile duct, bacteria, and inammation in
the bile duct; it also improves liver function, repairing the
damaged bile blood barrier. Only after the expansion of the
stula lithotripsy can the incidence of complications be
reduced. Based on this procedure, the other channel time can
be established. MI-3DVS is used to simulate puncture and
ostomy repeatedly, avoiding important blood vessels such as
a thoracic cavity, celiac intestine, hepatic artery, portal vein,
and hepatic vein. Percutaneous liver lithotripsy at stage I was
performed in patients with or without a history of biliary
tract surgery. Sixteen cases of lithotripsy at stage I and 23
cases of lithotripsy at stage II were successfully performed,
respectively.
Combined endoscopic treatment refers to the use of two or
three minimally invasive techniques such as laparoscope,
choledochoscope, and duodenoscope in the simultaneous or
sequential diagnosis and treatment of cholelithiasis. This
strategy can make up for the limitations and shortcomings of
a single method, avoid their respective shortcomings, and
aggregate their respective advantages. Multi-endoscopies
combined with minimally invasive treatment for cholelithiasis
has become increasingly mature, forming a combined
minimally invasive treatment system based on laparoscopy,
digestive endoscopy, choledochoscopy, etc. The clinical
application has shown that the minimally invasive treatment
of cholelithiasis with multiple endoscopies is superior to the
traditional surgical treatment or the minimally invasive
treatment alone.
8.8.1 Laparoscopy Combined
withCholedochoscopy
The preoperative preparation, patient positioning, and the
operating orice of the abdominal wall in laparoscopic choledochoscopy combined with choledochoscope for the treatment of cholelithiasis are similar to that of conventional
laparoscopic cholecystectomy. Laparoscopic cholecystectomy is usually performed rst, followed by laparoscopic
biliary exploration. If the diameter of the cystic duct is relatively thick, a choledochoscope can be inserted into the
182
Z. Tang and C. Fang
cystic duct for biliary exploration. If the cystic duct is thin,
the anterior wall of the common bile duct is separated and
exposed. After puncture conrmation, the common bile duct
is cut along the longitudinal axis of the common bile duct.
The common bile duct can also be cut through the stump of
the cystic duct. Usually, the choledochoscopy enters the
proximal bile duct from the right anterior axillary foramen
and enters the distal bile duct from the inferior hilar foramen.
The proximal bile duct stones should be removed rst and
then the distal bile duct stones. For those with residual stones
in the intrahepatic bile duct but the lower end of the common
bile duct is unobstructed, the T-tube is placed for drainage;
which is extracted from the right central line of the clavicle
through the subcostal foramen for postoperative angiography and lithotomy. For cholelithiasis complicated with intrahepatic bile duct stricture or duodenal papillary stenosis,
balloon dilatation with laparoscopy, and a choledochoscope
is feasible. The common hepatic duct is cut close to the narrow side and observe “head on” the opening of the hepatic
duct. The curved forceps are expanded slightly, and the zebra
guidewire is inserted into the intrahepatic bile duct at a certain depth, and the balloon is dilated along the guidewire to
dilate the stenosis of the hepatic duct branches I and II.For
patients with duodenal papillary stenosis, the balloon can be
guided into the duodenal cavity by a guidewire, and the balloon is pulled back into the bile duct for 2cm, then the pressure pump is attached to the balloon, and the catheter
expanded with water injection. Laparoscopy combined with
choledochoscopy is suitable for primary and secondary cholelithiasis when the diameter of choledocholithiasis is more
than 1.0cm. Patients with a large number of intrahepatic bile
duct stones without absolute stricture of intrahepatic bile
duct and whose Oddi sphincter function is excellent; when
the incision of duodenal diverticulum and paradiverticular
papilla are difcult with duodenal endoscopy; Mirizzi syndrome and elderly patients, patients who cannot tolerate
multiple endoscopy treatments.
8.8.2 Laparoscopy Combined
withDuodenoscopy
followed by net basket extraction or balloon lithotomy
without EST, to avoid papillary incision and complications
and to preserve the integrity of the nipple and sphincter
function. For stones with a diameter of 1–2cm, especially
for those with a hard-papillary texture and inammatory
stenosis, the EST is performed, and the incision direction is
controlled within the fan-shaped range of 11–2 o’clock. The
main incision is a mid-incision, which can retain 50% of the
basic sphincter pressure. Stones with a diameter of more
than 2 cm are treated by plasma-hydraulic lithotripsy or
holmium laser lithotripsy, and then removed by a net basket
and balloon. Usually, bile duct stones are removed under
duodenoscope, and LC should be performed after pancreatitis
and cholangitis are obviously alleviated or subsided. This
combined method is suitable for patients with
choledocholithiasis, suspected choledocholithiasis or
duodenal papillitis, duodenal papillary stenosis, and biliary
pancreatitis caused by it, as well as obstructive cholangitis.
8.8.3 Choledochoscopy Combined
withDuodenoscopy
Choledochoscopy combined with duodenoscopy, is mainly
used for patients with residual stones after biliary tract
recurrence. Residual stones less than 0.7cm in diameter are
removed through the T-tube sinus choledochoscopy by the
stone basket. The patients with intrahepatic bile duct stones
accompanied by stricture of the distal bile duct can be
examined by choledochoscope, and then stones can be
removed with a stone basket, biopsy forceps, anterior
choledochoscope, and balloon catheter. Hard removal of
stones with a diameter of more than 0.7cm or larger irregular
stones can lead to sinus injury. If the common bile duct is
narrow and the stones are embedded in the lower part of the
common bile duct, it is difcult to obtain the stone by
choledochoscope alone. A choledochoscope can be used to
push stones into the common bile duct and duodenal orice
under direct vision and then combined with lithotripsy and
duodenoscopy, stones can be removed.
Laparoscopy, combined with duodenoscopy in the treatment
of biliary stones, can also be sequential. However, as for
which one is better, opinions are diverse. Most scholars
advocate two stages, especially for those with biliary
pancreatitis and obstructive cholangitis. First, endoscopic
retrograde cholangiopancreatography (ERCP) is performed
to determine the distribution, number, size, and bile duct
lesions of the stones. Then endoscopic sphincterotomy (EST)
or endoscopic papillary balloon dilation (EPBD) is performed
to remove the stones with a net basket and balloon. Stones
with a diameter of less than 5mm are treated with EPBD,
8.8.4 Combined Use ofDuodenoscopy,
Laparoscopy, andCholedochoscopy
For complex cholelithiasis, which cannot be solved by one or
two endoscopies, duodenoscopy, laparoscopy, and
choledochoscopy can be used. Laparoscopy combined with
choledochoscopy and duodenoscopy is also performed in
two stages. ERCP is rst performed to determine the size,
number, and distribution of bile duct stones. If the stone is
difcult to remove, endoscopic nasobiliary drainage tube
(ENBD) or EST+ENBD should be performed. Laparoscopic
8 Application ofEndoscopic Techniques inBiliary Tract Surgery
183
common bile duct exploration and choledochoscopic lithotripsy should be performed when the patient’s condition is
improved. The placement of the ENBD tube under duodenoscopy is an essential step in three-mirror combined choledochotomy. Its functions include: improving the general
condition of the patient, biliary decompression, and serving
as a marker for choledocholithotomy during operation; as a
biliary stent after an operation to drain bile and reduce the
internal pressure of the biliary tract. The integrity and normal
physiological function of the bile duct can be maintained
with a T-tube during the operation. After the operation, cholangiography through the ENBD tube can be used to observe
whether there are residual stones.
Multi-mirror combined with minimally invasive therapy,
has become the trend of clinical treatment of various surgical
diseases and has a broad application prospect. With the
improvement and innovation of minimally invasive devices
and the popularization of minimally invasive concepts such
as the application of robotic surgery systems, the difculty of
laparoscopic minimally invasive surgery has been dramatically reduced. The improvement and innovation, of endoscopic equipment and the combined application of
endoscopic and other imaging techniques and treatment
techniques, has greatly facilitated the diagnosis and treatment of biliary diseases. It is believed that more progress
will be made in employing the combination of multiple
endoscopes, and the expanding indications for use will benet more patients with cholelithiasis.
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Application of3D Visualization
forBlood Supply ofExtrahepatic
Bile Ducts
ChihuaFang, JianYang, andXuChang
9
9.1 Introduction
In the twenty-rst century, primary research in biliary tract
surgery has realized remarkable achievements with the tremendous advances of related sciences such as molecular
biology, molecular genetics, medical imaging, and clinical
anatomy. Issues including the prevention and treatment of
ischemic biliary diseases after liver transplantation, and the
important role of extrahepatic bile duct blood supply in the
occurrence and prevention of biliary tract surgery diseases,
are also emerging. Hepatic artery variation is high, and so it
is vital to take advantage of 3D visualization technology, to
identify and then protect the variant arteries during surgery.
The incidence of biliary complications after liver transplantation ranges between 5% and 35% (Ayoub et al. 2010;
Balderramo etal. 2011), which is one of the main reasons
leading to graft failure or even mortality. With the improvement of the methods and techniques for anastomosis in liver
transplantation, the biliary complications caused by technical issues are decreasing, and ischemic-type biliary lesions
(ITBL) are the primary type of biliary complications after
liver transplantation. Among the various causes of biliary
ischemia, the destruction of bile duct blood ow is signicant. Notably, the occurrence of extrahepatic bile duct hemorrhage, traumatic bile duct stenosis, and biliary anastomotic
stula may be related to bile duct blood supply injury, so
attention has been increasingly paid to the blood supply of
the bile duct in hepatobiliary surgery.
C. Fang (*) · J. Yang
Zhujiang Hospital, Southern Medical University,
Guangzhou, China
X. Chang
Panyu District Hospital of Traditional Chinese Medicine,
Guangzhou, China
9.2 Study onBlood Supply
ofExtrahepatic Bile Ducts
andConstruction ofIts 3D
Visualization Platform
9.2.1 Historical Evolution ofResearches
onBlood Supply ofExtrahepatic
Bile Ducts
Previous studies on the blood supply of extrahepatic bile
ducts were mainly carried out on cadavers and animal models. In 1948, Shapiro and Robillard rst described the arterial
blood supply of the common and hepatic ducts with reference to the common duct injury and theorized that arterial
injury may induce biliary stricture and thereby aggravate a
biliary injury (Shapiro and Robillard 1948). Their theory has
stimulated the attention of clinicians and anatomists. Park
etal. (1999) observed 58 cases of cadaveric specimens and
realized that the basic blood supply of the biliary tract was
derived from two to ve branches of the posterior duodenal
or superior pancreaticoduodenal artery. They anastomosed
with each other and eventually coincided with the branches
of the right hepatic artery and the gallbladder artery, forming
a vibrant vascular network around the bile duct. The blood
supply sources differ for each segment of the biliary tract. In
the hilar part, the bile duct and the rst, the secondary hepatic
duct are mainly supplied by the branches of the right hepatic
artery and the cholecystic artery. The branches of the posterior duodenal artery and the superior pancreaticoduodenal
artery were mainly distributed to the upper part of the duodenum of the common bile duct and the posterior and lower
segments of the duodenum. In contrast, the branches of the
proper hepatic artery were not the main nutrient vessels of
the bile duct.
Northover etal. (1980) observed the blood supply of the bile
duct by scanning electron microscopy of microvascular resin
casts. In addition to further conrming the conclusion of Park,
they also found another critical source of bile duct blood supply
from the superior mesenteric artery. Because it runs behind the
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
C. Fang, W. Y. Lau (eds.), Biliary Tract Surgery, https://doi.org/10.1007/978-981-33-6769-2_9
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