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Surg Endosc. 2013 Aug;27(8):3009-15. doi: 10.1007/s00464-013-2837-3. Epub 2013 Feb 23.

Laparoendoscopic single-site common bile duct exploration using the manual manipulator.

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Department of Surgery I, School of Medicine, University of Occupational and Environmental Health Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Japan.



Laparoendoscopic single-site (LESS) surgery has developed as a new surgical modality that has increased cosmetic benefits over conventional endoscopic surgery. However, there are no reports about LESS surgery in common bile duct exploration. This report presents a LESS surgery to manage CBD stones by laparoscopic choledochotomy and C-tube placement with favorable outcomes.


This retrospective review analyzes 13 patients who underwent LESS CBD exploration with C-tube drainage for choledocholithiasis. The technique is herein described and the outcomes measured. The Radius Surgical System (Tübingen Scientific Medical, Tübingen, Germany) is a flexible manual manipulator that was applied for suturing and ligation to overcome the difficulties associated with LESS surgery.


The diameters of the CBDs ranged from 12 to 20 mm, the median number of stones was 5.8, and the median diameter of stones was 9 mm. All of the routine procedures including choledochotomy, intraoperative ultrasound, choledochoscopy, and intraoperative cholangiography guidance were performed. Stone clearance from the CBD was achieved for all but one of the patients. It was possible to close the common bile duct opening with regular forceps, but this required extra effort compared to conventional laparoscopic surgery. On the other hand, the manual manipulator enabled the optimal penetration angle and was useful for both intracorporeal suturing and ligation for the closure of the common bile duct opening. The manual manipulator also helped to overcome in-line viewing and hand/instruments collisions, which are common problems in LESS surgery. No mortality was associated with this procedure, and two wound infections were drained without anesthesia. No recurrent stones were observed during the follow-up period.


LESS surgery was successfully applied to CBD exploration as an available alternative to conventional laparoscopic surgery. This method is technically feasible and produces superior cosmetic results. The manual manipulator may therefore have several advantages for performing LESS surgery.

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