Invest Clin 64(2): 165 - 172, 2023 https://doi.org/10.54817/IC.v64n2a03

Corresponding author: Tie Qiao, General Surgery, the Second People’s Hospital of Panyu Guangzhou, Panyu Dis-

trict, Guangzhou, China. Email: cmff75@163.com; Tel: +86-13928793206.

Laparoscopic and Seldinger techniques

for the treatment of concomitant

gallstones and choledocholithiasis.

A retrospective study

Ruijin Song1, Li Feng2, Xiang Li3, Xueyi Liu3, Bo Yang4, Ming Gong1 and Tie Qiao5

1Interventional Department, the People’s Hospital of Pengzhou, Chengdu, China.

2Nutriology Department, the People’s Hospital of Pengzhou, Chengdu, China.

3Hepatobiliary Surgery, Guangdong Tongjiang Hospital, Guangzhou, China.

4Hepatobiliary and Pancreatic Surgery, the People’s Hospital of Pengzhou, Chengdu,

China.

5General Surgery, the Second People’s Hospital of Panyu Guangzhou, Guangzhou,

China.

Keywords: minimally invasive cholelithotomy; cholelithiasis and choledocholithiasis;

postoperative recovery.

Abstract. This study aimed to determine the efficacy and safety of a mini-

mally invasive combined approach for concomitant stone clearance of choleli-

thiasis and choledocholithiasis. From November 2018 to March 2021, 30 pa-

tients were enrolled in this retrospective study that compared two methods of

treating combined cholelithiasis and choledocholithiasis. The study comprised

two groups: 15 patients in Group A underwent combined laparoscopic and

Seldinger techniques for complete stone clearance, retaining the gall bladder

in situ. In Group B, 15 patients underwent laparoscopic cholecystectomy and

choledocholithotomy with T-tube drainage. The rates of successful completion

of the operations, procedure-related complications, length of hospitalization,

hospital cost, and patient satisfaction were compared between the two groups.

The two groups had no differences in general patient characteristics, and all

procedures were successfully completed. Compared to Group B, patients in

Group A had a shorter operative time (84 vs. 105 min), less blood loss (10 vs.

28 mL), were less expensive, and had a shorter postoperative recovery. A single

patient in group B developed bile leakage. The satisfaction rate was 93% in

Group A, in contrast to 80% in Group B. The combined use of laparoscopic and

Seldinger techniques to achieve complete stone removal in patients with con-

comitant cholelithiasis and choledocholithiasis was demonstrated to be safe

and successful.

166 Song et al.

Investigación Clínica 64(2): 2023

Técnicas laparoscópica y de Seldinger para el tratamiento

de cálculos biliares y coledocolitiasis concomitantes.

Un estudio retrospectivo.

Invest Clin 2023; 64 (2): 165 – 172

Palabras clave: colelitotomía mínimamente invasiva; colelitiasis y coledocolitiasis;

recuperación postoperatoria.

Resumen. Este estudio tuvo como objetivo determinar la eficacia y la se-

guridad de un enfoque combinado mínimamente invasivo para la eliminación

de cálculos de la vasícula biliar y del conducto colédoco. Desde noviembre de

2018 hasta marzo de 2021, treinta pacientes se inscribieron en este estudio

retrospectivo que comparó dos métodos combinados de tratamiento de cole-

litiasis y coledocolitiasis. El estudio comprendió dos grupos: en el Grupo A

15 pacientes se sometieron a coledocotomía laparoscópica y a colecistostomía

con la técnica de Seldinger para el tratamiento simultáneo de la litiasis de la

vesícula biliar y coledociana, dejando la vesícula biliar in situ. En el grupo B, 15

pacientes se sometieron a colecistectomía y coledocotomía laparoscópica con

drenaje del tubo T. Las tasas de conclusión exitosa de las operaciones, compli-

caciones relacionadas con el procedimiento, la duración de la hospitalización,

el costo hospitalario y la satisfacción del paciente se compararon entre los dos

grupos. No hubo diferencias en las características generales del paciente entre

los dos grupos y todos los procedimientos se completaron con éxito. En compa-

ración con el grupo B, los pacientes en el Grupo A tuvieron un tiempo operativo

más corto (84 frente a 105 min), menos pérdida de sangre (10 frente a 28 mL),

eran menos costosas y tenían una recuperación postoperatoria más corta. Un

solo paciente en el Grupo B desarrolló fugas biliares. La tasa de satisfacción

fue del 93% en el Grupo A en contraste con el 80% en el Grupo B. La técnica

laparoscópica combinada con la colecistostomía de Seldinger para lograr la

eliminación completa de cálculos en pacientes con cálculos de la vesícula biliar

y del colédoco fue segura y exitosa.

Received: 11-11-2022 Accepted: 09-12-2022

INTRODUCTION

Cholelithiasis is a commonly encoun-

tered condition caused by several factors,

such as metabolic abnormalities and un-

healthy lifestyle habits 1. The treatment of

patients with combined cholelithiasis and

choledocholithiasis is more complex. In re-

cent years, multiple operative approaches

have been undertaken to address both prob-

lems. These have included the combination

of laparoscopic cholecystectomy (LC) with

laparoscopic common bile duct exploration

(LCBDE), endoscopic retrograde cholan-

giopancreatography (ERCP), and LC plus

transcystic exploration 2-4. There have been

advantages and disadvantages to all these

strategies. Similar to the classic open cho-

lecystectomy and CBD (common bile duct)

exploration, a T-tube has often been placed

Laparoscopic with Seldinger techniques for choledocholithiasis 167

Vol. 64(2): 165 - 172, 2023

during LCBDE to prevent postoperative bile

leakage. An associated potential of damage

to the CBD exists, and the postoperative

management and inconveniences of the T-

tube are well known. Transcystic stone re-

moval can avoid the need for a T-tube and

obviate the need and risk of postoperative

ERCP for stone management.

Additional minimally invasive treat-

ments are needed for patients with choleli-

thiasis combined with choledocholithiasis.

In 2016, Pet et al. 2 reported the placement

of an intraoperative endoscopic nasobiliary

drainage (ENBD) tube in the common bile

duct with primary closure of the CBD to

prevent postoperative bile leakage. This was

accomplished using Tri-scope (laparoscope,

choledochoscope, and gastroscope) surgery,

which appeared feasible, safe, and cost-effec-

tive.

In the present study, we treated pa-

tients with concomitant cholelithiasis and

choledocholithiasis with a combination of

laparoscopic and Seldinger technology. Man-

agement involved a guide wire, catheter, and

balloon catheter placed into and through

the gallbladder into the CBD to clear the

stones. To provide a frame of reference, we

compared the outcomes of the above pa-

tients with those treated with laparoscopic

choledocholithotomy and T-tube drainage.

METHODS

Patients

Thirty patients (17 males, 13 females)

with concomitant cholelithiasis and cho-

ledocholithiasis were enrolled from Novem-

ber 2018 to March 2021. These patients

(age range, 24-80 years) were diagnosed

using computed tomography (CT) and mag-

netic resonance cholangiopancreatography

(MRCP). All patients underwent preopera-

tive physical examination, including blood

tests, to assess liver and kidney function,

urine amylase, and coagulation parameters.

Inclusion criteria included: no previ-

ous surgical treatment of the hepatobiliary

system, duodenum, or stomach and preop-

erative confirmation of concomitant choleli-

thiasis and choledocholithiasis by MRCP. The

gallstones were removed, leaving the intact

gallbladder in Group A. The cholecystecto-

my was performed in Group B.

Exclusion criteria in all two groups:

acute or suppurative inflammation of the

hepatobiliary system; mental illness; the

presence of pancreatic cancer, diabetes, or

other relatively serious diseases; and the

presence of severe lung or kidney problems.

Patients group

All patients signed informed consent.

The approach of surgery was performed ac-

cording to the principle of voluntary partici-

pation. This study was approved by the ethics

committee of our hospital (registration No.

ChiCTR2100047160).

Surgery techniques

Combined laparoscopic and Seldinger

techniques

Group A. Under satisfactory general en-

dotracheal anesthesia, a pneumoperitoneum

was established through a standard umbili-

cal incision, and two ports were placed 5. A

2-3 cm incision was made 10 mm below the

umbilical cord to establish pneumoperito-

neum by injecting CO2 and finding the gall-

bladder. The bottom of the gallbladder was

sutured with a traction line, and the bot-

tom of the gallbladder was filled with sterile

gauze to protect the tissues around the gall-

bladder. With laparoscopic visualization, the

gallbladder was elevated, and a 1-cm inci-

sion was performed. Bile was aspirated with

steady fixation of the gallbladder, and the

gallstones were completely removed using

a rigid choledochoscope. An 8.5-F Dawson-

Mueller drainage catheter was then inserted

into the gallbladder lumen under the guid-

ance of ﬂuoroscopy. Stone removal was per-

formed after the alleviation of cholecystitis

or cholangitis at a mean of 4.5 days after

cholecystostomy. The drainage catheter was

then exchanged over a 0.035-inch super-stiﬀ

168 Song et al.

Investigación Clínica 64(2): 2023

guide wire to an 8-F sheath. A 5F catheter

(40 cm long) was introduced through the

sheath, and a 0.035-inch hydrophilic guide

wire was used to navigate the cystic duct.

After crossing the cystic duct, the guide

wire was further inserted down the common

bile duct (CBD) through the papilla of Vater

into the duodenum. The size, location, and

number of stones in the common bile duct

were determined by choledochography us-

ing iodixanol. A stone extractor was used to

remove the gallbladder directly for smaller

stones. For larger stones, a biopsy forceps

was used for crushing the stones before re-

moving them. According to the size of the

stones and the common bile duct dilatation,

a suitable balloon catheter was used to ex-

pand the duodenal papilla. The stone could

be pushed through the papilla into the duo-

denum using a stiff guide wire. Intraopera-

tive choledochography was performed again

to verify there were no residual stones and

patency of the common bile duct. After with-

drawing the guide wire and catheter, the

gallbladder incision was sutured, and the

abdomen was closed. The sheath was finally

exchanged with an 8.5-F Dawson-Mueller

drainage catheter in the gallbladder to allow

drainage and prevent complications.

In group A, the gallbladder was normal

in size, without structural abnormality, and

its wall was smooth without thickening. The

stones can move within the capsule, and it is

better if they are large and few.

Laparoscopic choledocholithotomy

and T-tube drainage

Group B. Under satisfactory general en-

dotracheal anesthesia, a pneumoperitoneum

was established through a standard umbili-

cal incision, and a four-port technique was

performed 6,7. The gallbladder was dissected,

and the cystic and common bile ducts were

visualized and safely dissected. The cystic

duct was ligated with No.7 silk, and the com-

mon bile duct was opened using hook elec-

trocautery at the point where the cystic duct

joins the common bile duct. The stones were

removed using previous choledochoscopic ir-

rigation. If necessary, the operation was con-

verted to a laparotomy, and the CBD stones

were retrieved with choledocholithotomy

forceps through the infra xiphoid incision.

At the completion of the choledochoscopic

exploration, a T-tube was placed in the com-

mon bile duct, which was closed with a 3-0

absorbable suture, and the gallbladder was

then removed. The gallbladder bed drainage

tube and T-tube exited through laparoscopic

portholes. On postoperative day 2 or 3, the

drainage tube was removed if the drainage

was satisfactory. One month postoperatively,

after satisfactory T-tube cholangiography,

the T-tube was removed.

In group B, the gallbladder structure

was abnormal, and the cyst wall was thick-

ened. The contraction function of the gall-

bladder was lost.

Operative and postoperative comparison

parameters

Comparison parameters for the two

groups included operative success rate, op-

erative time and blood loss, postoperative

fasting time and complications, total hos-

pitalization time and expenses, and patient

satisfaction.

All patients were contacted postopera-

tively either by telephone or WeChat as well

as the scheduled one-month follow-up visit.

All 30 patients were successfully followed.

Statistical analysis

The SPSS 20.0 (SPSS Inc., Chicago, IL,

USA) software was used to analyze the data.

Measurement data were analyzed by the Stu-

dent’s t-test, and categorical data were ana-

lyzed by the Chi-square test or Fisher’s exact

test. Statistical significance was defined by

p<0.05.

RESULTS

General characteristics

The general characteristics of the pa-

tients in both groups are shown in Table 1.

Laparoscopic with Seldinger techniques for choledocholithiasis 169

Vol. 64(2): 165 - 172, 2023

There were no significant differences with

respect to age, aspartate aminotransferase

(AST), alanine aminotransferase (ALT), glu-

tamyl transpeptidase (GGT), globulin ratio,

direct bilirubin, uric acid, or creatinine.

Postoperative complications

The patients in both groups underwent

successful operations. Postoperative compli-

cations are detailed in Table 2. In group A,

one patient had elevated amylase and hema-

turia on the day of the operation but recov-

ered to normal with fasting and treatment

with somatostatin for two days. In group B,

one patient developed bile leakage after re-

moving the drainage tube three days post-

operatively. The remaining group B patients

were discharged with T-tubes from five to

seven days postoperatively.

Outcomes of procedures

The outcome parameters of operative

time, blood loss, postoperative times of fast-

ing and hospitalization, and expenses are tab-

ulated in Table 3. Group A patient outcomes

were significantly better than Group B with

regard to operative time, blood loss, fasting,

and hospitalization times (p<0.01). The two

groups had no significant difference in aver-

age hospitalization expenses (p= 0.745).

Clinical follow-up

Longer-term follow-up results are shown

in Table 4. The time needed to return to work

in Group A was significantly shorter than in

group B (p<0.001). Except for a single pa-

tient with incisional discomfort in Group A

and one case of upper abdominal discomfort

in Group B, no other problems were encoun-

tered at the 1-month follow-up. Patient sat-

isfaction rates of group A and B were 93%

(14/15) and 80% (12/15), respectively. In

group B, three patients noted that the time

interval the T-tube remained in place was too

long, which greatly impacted their daily life.

DISCUSSION

The development of minimally invasive

surgery has provided various options for treat-

ing concomitant cholelithiasis and choledocho-

lithiasis. The laparoscopic approach, enhanced

with choledochoscopy and duodenoscopy to

perform common bile duct exploration and li-

thotomy, has been recognized as unique mini-

mally invasive biliary surgery technology 8,9.

With the development of multi-disciplinary

consultation and joint treatment of diseases,

disciplines previously working independently

have been united, minimizing iatrogenic injury

and improving work efficiency.

Table 1

General characteristics of the two groups.

Characteristics Group A Group B p

Age (years) 60.67±12.06 56.07±16.54 0.391

Female 7 6

Male 8 9

Aspartate aminotransferase (U/L) 256.67±342.23 167.27±136.87 0.356

Alanine aminotransferase (U/L) 201.07±214.38 199.07±152.87 0.977

Glutamyl transpeptidase (U/L) 449.73±314.36 456.33±456.85 0.964

Globulin ratio 1.46±0.46 1.44±0.47 0.907

Direct bilirubin (umol/L) 39.85±28.07 33.80±30.94 0.579

Uric acid (umol/L) 275.67±98.13 299.27±91.68 0.502

Creatinine (umol/L) 64.80±14.10 72.80±20.58 0.225

The differences in data between groups were analyzed by the Student’s t-test.

170 Song et al.

Investigación Clínica 64(2): 2023

Extending these advanced combined

technologies, laparoscopy combined with the

Seldinger techniques described for stone clear-

ance when cholelithiasis is complicated with

choledocholithiasis offers advantages of mini-

mal tissue trauma, quicker recovery, and pres-

ervation of sphincter of Oddi’s anatomy and

function. The present study data would also

indicate this technique provides extraordinary

patient satisfaction.

With the increasing demand by patients

to maximize quality of life, increasing atten-

tion has been paid to gallbladder preserva-

tion 10,11. Although the long-term assessment

of this approach has yet to be fully reviewed,

combining laparoscopic and Seldinger tech-

niques to clear the gallbladder and CBD of

stones while preserving the gall bladder in

situ and avoiding the need for a T-tube pays

attention to the restoration of normal anat-

omy and function. Moreover, if gallstones re-

cur, the minimal tissue trauma of this opera-

tion should pose minimal scarring or other

issues if reoperation is needed.

However, this study has limitations.

The overall patient numbers were relatively

small, and the follow-up was limited to the

early postoperative period (one month). Ad-

ditionally, advanced laparoscopic skills are

required, and longer follow-ups with larger

patient series are necessary for the valida-

tion of the present findings.

As a conclusion, combined laparoscopic

and Seldinger techniques to clear stones in

patients with concomitant cholelithiasis and

choledocholithiasis, with preservation of the

gallbladder in situ, has the advantages of mini-

mal tissue trauma, quick recovery, avoidance of

a T-tube, high patient satisfaction, and restora-

tion of normal anatomy and function.

Table 3

Outcomes of procedures in the two groups.

Outcomes of procedures Group A Group B p

Blood loss (mL) 9.95±2.45 27.55±7.57 0.000

Operation time (min) 84.20±16.84 105.75±14.80 0.001

Fasting time (h) 24.15±11.21 43.65±11.55 0.000

Hospitalization time (d) 4.27±1.03 10.20±1.52 0.000

Hospitalization expenses (CnY) 16108.93±1366.11 16430.0±3516.5 0.745

The difference in data between groups was analyzed by the Student’s t-test.

Table 4

The follow-up results in the two groups.

Follow-up results Group A Group B p

Time return to work (d) 3.67±0.82 32.87±1.19 0.000

Number of people with discomfort (n) 1 1

Satisfaction rate (%) 93.3%(14/15) 80%(12/15) 0.598

The difference in “time return to work” between groups was analyzed by the Student’s t-test. The difference in

“satisfaction rate” between groups was analyzed by the Chi-square test.

Table 2

Postoperative complications in the two groups.

Postoperative

complications

Group A Group B p

Bile leakage 0 1 1.000

Residual stone 0 0

Postoperative acute

pancreatitis

0 0

The difference in data between groups was analyzed by

the Chi-square test.

Laparoscopic with Seldinger techniques for choledocholithiasis 171

Vol. 64(2): 165 - 172, 2023

ACKNOWLEDGMENTS

The authors would like to express their

gratitude to EditSprings.com (https://www.

editsprings.cn/) for the expert linguistic

services provided.

Funding

No.

Conflict of interests

All authors declare there are no con-

flicts of interest.

Author’s ORCID numbers

• Ruijin Song: 0000-0002-1111-9360

• Li Feng: 0000-0002-9233-4088

• Xiang Li: 0000-0001-7378-1846

• Xueyi Liu: 0000-0002-7167-0234

• Bo Yang: 0000-0002-4625-4706

• Ming Gong: 0000-0002-2064-3623

• Tie Qiao: 0000-0002-1294-0759

Author contributions

SJ and FL analyzed and interpreted the

patients’ data. SJ, LX, QT, GM and YB per-

formed the surgery. SJ and QT were major con-

tributors to writing the manuscript. All authors

read and approved the final manuscript.

Availability of data and materials

The datasets during the current study

could be available from the corresponding

author upon reasonable request.

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