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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