Bilobar Ultramini Percutaneous Hepatolithotomy

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Introduction: Hepatolithiasis is defined as the presence of stones in the bile ducts proximal to the confluence of the right and left hepatic ducts, irrespective of the coexistence of stones in the common bile duct and/or gallbladder. The symptoms of hepatolithiasis may include epigastric or right upper quadrant pain, jaundice, fever, and gastrointestinal symptoms. This disease can cause cholestasis, cholangitis, abscesses, postobstructive atrophy, and liver cirrhosis.1 Although the etiology of hepatolithiasis is not exactly known, it is believed that nutrition, environmental and genetic factors, and surgical operations play different roles.2,3 It frequently occurs after a hepatic portoenterostomy (such as a Kasai), with bile stasis and (possibly) bile infections being the main causes of calculi formation. Previous studies have reported a 53% incidence of hepatolithiasis after Kasai operations.3 The aim of hepatolithiasis treatment is to extract the stones and regain biliary drainage. Liver resection as well as less invasive procedures, such as percutaneous transhepatic cholangioscopy, peroral cholangioscopy, and extracorporeal shock wave lithotripsy, may be used for the treatment of hepatolithiasis.4,5 However, these procedures are not always effective, because bile duct anatomy differs, and they may not significantly reduce the intrahepatic stone burden. There is a risk of liver failure after an open liver resection, which is performed if there are multiple large stones, and a stone-free condition cannot be provided for the patient through other treatments. Therefore, an “ultramini percutaneous hepatolithotomy” (UM-PHL) was planned by the Necmettin Erbakan University Stone Diseases Diagnosis and Treatment Center based on decisions made by a urology, interventional radiology, and general surgery clinical team. It was hypothesized that it could provide less morbidity and a higher stone-free condition ratio. Materials and Methods: The patient information details and surgical technique are shown in the video provided. Results and Conclusion: Initially, the left intrahepatic bile ducts were accessed and the obstructing stones were extracted in 126 minutes, whereas the right intrahepatic bile ducts were accessed and treated in 103 minutes. This procedure was performed as one operation, and all of the stones in the patient's intrahepatic bile ducts were removed (stone free). At the 1 month follow-up, liver function tests were performed, which showed normal values, and no stones were seen in the intrahepatic bile ducts through ultrasonography. All of the patient's complaints and symptoms had disappeared, and she did not have any problems during any of her postoperative follow-ups. In postoperative cholangiography and abdominal ultrasonography, there were neither mechanical obstruction findings at the anastomoses nor stones. Pharmacotherapy is not recommended in the evidence-based clinical practice guidelines for cholelithiasis (2016)6 for hepatolithiasis treatment, so this patient was not started on any medications. The previously used methods were not effective in this patient, therefore, UM-PHL was performed. Our hepatolithiasis case is the first case in the literature from whom large stones were extracted using lithotomy with minimal width access, and a complete stone-free state was provided. In hepatolithiasis patients with a high stone burden, an UM-PHL is a safe and effective method for removing stones. No competing financial interests exist. Runtime of video: 9 mins 13 secs

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