Laparoscopic primary suture of the common bile duct in patients with common bile duct stones: a comparative analysis of two suturing methods in terms of safety, efficacy, and convenience with 16-month follow-up

Abstract

Background

Primary suturing of the common bile duct (CBD) is increasingly used in laparoscopic common bile duct exploration (LCBDE) for selected patients, though the optimal suturing method remains unclear. This study compares the efficacy of continuous versus interrupted sutures for primary CBD closure in patients with CBD stones.

Methods

A retrospective analysis was conducted on 120 patients with CBD stones who underwent primary CBD closure at Yancheng First People’s Hospital from October 2022 to December 2023. Data included demographics, hospital stay, complications, and follow-up outcomes. Of these, 69 received continuous sutures, and 51 received interrupted sutures.

Results

No significant differences were found in age, gender, body mass index (BMI), CBD diameter, preoperative bilirubin levels, or stone residuals between groups. The incidence of postoperative fever, bile leakage, electrolyte disturbances, bleeding, wound infection, and CBD stricture was similar. Continuous suturing required less operative time than interrupted suturing (p < 0.01).

Conclusion

Both continuous and interrupted suturing techniques are safe and effective for CBD closure in selected patients, though continuous suturing is more time-efficient.

Introduction

Common bile duct stones are a prevalent biliary disease, accounting for approximately 10–15% of all bile duct stone cases, with an incidence rate second only to gallstones [1, 2]. The incidence of bile duct stones is significantly higher in East Asian populations compared to Western countries. Although the exact cause remains unclear, a high-fat diet and low water intake are commonly associated with the elevated incidence of bile duct stones [3]. In addition, bile duct stones often recur after treatment, significantly impacting quality of life and health. Currently, CBD stones are treated through endoscopic retrograde cholangiopancreatography (ERCP), CBD exploration surgery, percutaneous transhepatic biliary drainage (PTBD), and sinus tract stone removal [4]. However, ERCP carries risks such as stone removal failure, pancreatitis, and bleeding. Conventional common bile duct exploration and duct stone removal can lead to decreased quality of life, T-tube displacement, bile loss, electrolyte imbalance, and delayed recovery, all of which are related to T-tube complications [5]. PTBD is a method for managing jaundice in patients with common bile duct stones, but it is not a curative treatment for common bile duct stones [6]. laparoscopic common bile duct exploration (LCBDE) is increasingly used to treat CBD stones, yielding favorable therapeutic outcomes [7]. Traditionally, bile drainage following CBD surgery is managed with a T-tube, yet T-tube drainage carries several drawbacks. Consequently, for suitable patients, more physicians are inclined toward primary closure of the CBD. However, there remains no consensus on the optimal suturing technique for the CBD incision [8, 9].

In terms of suturing techniques, interrupted and continuous sutures are two commonly used methods. Interrupted suturing involves placing individual sutures at separate points along the wound, with each suture being adjusted and tightened as needed. This method is typically used for more complex wounds or when fine control is required. On the other hand, continuous suturing involves using a single suture thread to stitch the wound from one end to the other in a continuous line, which is faster and allows for more even tension distribution, making it suitable for most routine wounds. Although both methods have been widely applied in other clinical areas, in the context of primary closure of the common bile duct, previous literature mainly focuses on the suture effectiveness of the two methods. However, there is no definitive conclusion regarding the specific indications for the use of each suture technique. In this study, we compared the intraoperative suture time, intraoperative conditions such as postoperative bile leakage, and clinical outcomes such as postoperative indicators between 120 patients with common bile duct stones who underwent primary continuous suturing or interrupted suturing of the common bile duct, in order to evaluate the safety, effectiveness, convenience, and impact on quality of life of the two suturing methods.

Methods

Study design

This retrospective cohort study included 120 patients with CBD stones, divided into two groups: 69 patients who received continuous suturing and 51 patients who received interrupted suturing, to evaluate the safety, efficacy, and convenience of these two primary suturing techniques for the CBD. Patients diagnosed with CBD stones combined with gallbladder stones who underwent LCBDE with primary closure of the CBD (LCBDE-PCCBD) without biliary drainage at our hospital from October 2022 to December 2023 were included. All LCBDE-PCCBD procedures were performed by surgeons with over 10 years of clinical experience who had independently and completed at least 100 CBD explorations. In compliance with medical ethical standards, written informed consent was obtained preoperatively from all patients and/or their guardians.

Patients enrollment and data collection

Relevant data were collected and analyzed for enrolled patients. All clinical data were sourced from our hospital’s medical records database, while quality-of-life scores were obtained through postoperative telephone or outpatient follow-up. The inclusion criteria were as follows: (1) patients with a confirmed diagnosis of bile duct stones (BDS); (2) consent to primary closure of the CBD; (3) preoperative magnetic resonance cholangiopancreatography (MRCP) confirming a CBD diameter of ≥ 7 mm [9]; (4) no residual CBD stones intraoperatively; (5) absence of preoperative obstructive jaundice; (6) absence of bile duct injury intraoperatively; (7) no coexisting hepatobiliary malignancy; (8) patient consent for LCBDE-PCCBD; and (9) detailed clinical data for analysis and follow-up completion. Exclusion criteria included: (1) patients with hepatobiliary malignancy (Adenocarcinoma, adenosquamous carcinoma, squamous cell carcinoma, undifferentiated carcinoma, etc.); (2) those who received T-tube or nasobiliary drainage, or ERCP; (3) patients with concurrent acute pancreatitis; (4) patients with preoperative obstructive jaundice; (5) patients with clinical data insufficient for analysis; and (6) patients lost to follow-up; (7) Residual bile duct stones were found intraoperatively and could not be removed. The outcomes observed included demographic data, pre- and postoperative liver function results, intraoperative conditions, postoperative recovery, and clinical outcomes during the follow-up period. All patients were required to return for a follow-up at the hospital one month after surgery to check liver function, undergo hepatobiliary ultrasound, and complete the Gastrointestinal Quality of Life Index (GIQLI) scoring in the outpatient clinic, a validated tool used to assess quality of life after bile duct surgery [10, 11]. Subsequent follow-ups included annual liver function tests and hepatobiliary ultrasounds. The definition of infection was the presence of fever, elevated white blood cells, and positive bacterial culture within one week post-surgery. Bile leakage was defined as the presence of bile drainage from the drainage tube or the occurrence of abdominal pain and bile peritoneal fluid after the drainage tube was removed. Recurrent bile duct stones were defined as the presence of recurrent stones in the common bile duct, confirmed by hepatobiliary ultrasound during postoperative follow-up. Postoperative complications were assessed using the Clavien-Dindo surgical complication classification system [12] and the bile leakage classification criteria [13]. Severe complications refer to Grade III or IV complications in the DC classification or Grade C in the bile leakage classification criteria.

Surgical procedures

Patients were positioned in a head-down, foot-up orientation with the right side elevated by 30°. Following endotracheal intubation and general anesthesia, a pneumoperitoneum was created by puncturing below the umbilicus, maintaining CO₂ pressure at 10–13 mmHg. The standard four-trocar technique was employed: a 10 mm trocar was placed subumbilically as the laparoscopic observation port, a 10or 12 mm trocar served as the primary operating port for choledochoscopy, stone removal, and CBD incision repair, a 5 mm trocar was placed at the right midclavicular line below the ribs, and another 5 mm trocar was inserted along the anterior axillary line as an auxiliary port.

Initially, if necessary, abdominal adhesions with the gallbladder were separated. The Calot’s triangle was then dissected to expose the cystic duct and cystic artery while identifying the CBD. The cystic artery was clamped and divided. The cystic duct was clamped, and the gallbladder was retracted to expose the CBD fully. Using a low-power electrocautery, the serosa and anterior wall of the CBD were carefully incised; based on preoperative MRI-MRCP findings, a longitudinal incision approximately 7 mm or slightly larger than the stone diameter was made. A choledochoscope with a stone retrieval basket was used to remove bile duct stones (BDS). The choledochoscope was advanced distally to the duodenal papilla, where it opened and closed fully in response to bile pressure changes from choledochoscope irrigation, and proximally to the second-order hepatic ducts. This process was repeated three times to confirm complete stone clearance. If residual stones are found during surgery and cannot be removed, a T-tube drainage is performed to facilitate subsequent stone removal using choledochoscopy.

After complete stone clearance, depending on intraoperative circumstances, primary continuous suturing of the CBD was performed using 4–0 absorbable barbed sutures (V-LOCK, Covidien Inc., Tullamore, Ireland), or interrupted suturing was done using 4–0 absorbable sutures (Polysorb, GL- 45-MG, Covidien Inc., Tullamore, Ireland) with approximately 1.0 mm edge spacing and 1.5 mm suture intervals (Fig. 1). If bile leakage occurred after suturing, interrupted suturing with 4–0 absorbable sutures (Polysorb, GL- 45-MG, Covidien Inc., Tullamore, Ireland) was used to repair the leak, with at least four knots per interrupted suture. Finally, the cystic duct was divided, and the gallbladder was completely excised, leaving a clip on the residual cystic duct stump. After completing laparoscopic cholecystectomy, we routinely observe the common bile duct suturing site to confirm whether there is bile leakage. If bile leakage is present, we will reinforce the leaking bile duct with 4–0 absorbable sutures. If it was challenging to remove the gallbladder or stones from the abdominal cavity, the incision was appropriately enlarged or the items were placed in a retrieval bag and crushed before removal. Before concluding the procedure, a routine abdominal drain was placed in the gallbladder and spleen fossae (Fig. 2).

Fig. 1

Steps for Continuous Primary Suturing of Common Bile Duct Stones under Laparoscopy. A Start suturing the common bile duct approximately 2 mm from the upper end of the cut. B-C Continuous full-thickness suturing of the common bile duct. D Complete the first stage of the common bile duct suturing using continuous suturing

Fig. 2

Steps for Interrupted Primary Suturing of Common Bile Duct Stones under Laparoscopy. A Start suturing the common bile duct about 2 mm from the upper end of the incision. B-E Perform interrupted full-thickness suturing of the common bile duct. F Complete the first stage of the common bile duct suturing using interrupted suturing

Patient management and follow-up

All patients were discharged around day 4 after the removal of the splenic drainage tube, depending on the drainage condition. A liver function test was completed before discharge. On day 9, patients returned to the hospital. If no abnormalities were observed in the gallbladder drainage tube, it was removed. Sutures were removed on day 14, with those returning for suture removal in the outpatient clinic completing a quality of life assessment (GIQLIQ) [10, 14]. Patients whose sutures were removed at other hospitals were followed up via phone. Within six months after surgery, all patients were required to undergo at least one liver function test and an ultrasound scan of the liver and biliary system (USS) to assess recovery and check for any bile duct stenosis. Based on the results, further tests such as MRI-MRCP and subsequent treatment were determined. For patients with recurrent BDS, ERCP was performed. If the patient experiences recurrent bile duct stones, ERCP is the first-line treatment. If ERCP fails or if stones recur, laparoscopic common bile duct exploration with stone removal will be performed again. For patients with biliary stricture after primary suturing, if obstructive jaundice symptoms develop, biliary stent implantation will be carried out. During follow-up, if liver function and imaging tests were normal and the patient reported no subjective discomfort, no further examinations were conducted.

Statistical analysis

Statistical analyses were performed using SPSS software version 29.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were presented as mean ± standard deviation and analyzed using the t-test. Categorical variables were expressed as percentages and analyzed with the chi-square test. A p-value of < 0.05 was considered statistically significant.

Results

Demographic data and intraoperative findings

There were 30 male and 39 female patients in the continuous suture group,, with an average age of 58.44 ± 14.98 years. The interrupted suture group included 24 males and 27 females, averaging 57.91 ± 14.78 years. Table 1 presents Demographic Data and Intraoperative Findings. The results indicated no statistically significant differences between the two groups for these parameters (P > 0.05). However, the mean suturing time for continuous suturing was 14.71 ± 2.04 min, compared to 19.45 ± 1.42 min for interrupted suturing, showing a statistically significant difference (p < 0.01).

Table 1 Demographic data and intraoperative findings

Postoperative clinical indicators and quality of life changes

We analyzed postoperative clinical indicators and quality of life in both suture groups. In the continuous suture group, the mean postoperative total bilirubin level was 17.32 ± 8.72; in the interrupted suture group, it was 15.15 ± 5.39. For biliary surgery, whether the bile duct heals properly after the operation is a major concern for every surgeon. In the continuous suture group, one patient (1.45%) patient experienced postoperative infection, two patients (2.9%) had postoperative bleeding, two patients (2.9%) developed bile leakage, and one patient (1.45%) had stone recurrence. In the interrupted suture group, the occurrences were as follows: Two patients (3.92%) experienced infection, one patient (1.96%) experienced bleeding, two patients (3.92%) had bile leakage, and one patient (1.96%) had stone recurrence. No patients in either group developed biliary stricture or had malignancies identified on postoperative pathology. All postoperative infection cases were treated and cured with high-grade antibiotics. Postoperative bleeding was controlled with hemostatic agents, bile leakage was managed conservatively with adequate drainage, and recurrent stones were treated accordingly.

The average postoperative hospital stay was 5.12 ± 1.77 days for the continuous suture group, with a GIQLIQ score of 132.74 ± 8.25, an average hospital cost of 15,990.68 ± 2,059.77 RMB, and an average follow-up period of 16.68 ± 4.46 months. The corresponding values in the interrupted suture group were 5.21 ± 2.01 days, a GIQLIQ score of 132.06 ± 8.98, an average hospital cost of 16,020.48 ± 1,634.85 RMB, and a follow-up period of 16.33 ± 4.33 months. There were no statistically significant differences between these indicators (Table 2).

Table 2 Postoperative complications

Discussion

This study aims to systematically compare the clinical outcomes of continuous versus interrupted suturing techniques in primary closure after LCBDE. The focus is on the safety, efficacy, and convenience of suturing, while also evaluating postoperative quality of life between the two techniques. The findings are expected to provide evidence-based recommendations for optimizing suturing strategies in clinical practice.

In terms of safety and efficacy, Wang et al. [15] reported that in the continuous suturing group, the intraoperative blood loss was 45.65 ± 30.31 mL. Bile leakage occurred in 5 patients (2.59%), postoperative bleeding in 3 patients (1.55%), and stone recurrence in 9 patients (4.66%), with 2 patients (1.04%) requiring reoperation due to recurrence. A total of 4 patients (2.08%) experienced Grade II or higher complications. Jiang et al. [16] research showed that postoperative blood loss in the continuous suturing group was 10 patients (10–15) mL. The incidence of postoperative bile leakage was 4 patients (4.3%), postoperative bleeding occurred in 1 patient (1.1%), and postoperative cholangitis in 1 patient (1.1%). The total postoperative complication rate was 11 patients (11.1%), with 2 patients (2.1%) experiencing severe complications—both underwent ERCP due to recurrent stones. In this study, the average blood loss in the continuous suturing group was 31.47 ± 3.99 mL, the complication rate was 9.8%, and the severe complication rate was 2 patients (1.4%). The higher blood loss observed in this study compared to Jiang’s study may be due to the latter using estimated values. However, the incidence of complications and severe complications in this study was generally consistent with previous research.

Cai et al. [17] reported that intraoperative blood loss in the interrupted suturing group was 39.3 ± 12.4 mL, with 6 patients (4.5%) experiencing postoperative bile leakage. No patients developed residual stones, postoperative pancreatitis, or other complications. Zhang et al. [18] found that the overall postoperative complication rate in the interrupted suturing group was 15% (6 patients), including 2 cases (5%) of bile leakage, 1 case (2.5%) of acute pancreatitis, and 1 case (2.5%) of subhepatic bile stasis. The incidence of severe complications was 5%. In our study, the incidence of severe complications in the interrupted suturing group was 10.2%, with a severe complication rate of 2.0% (1 patient). Compared to the studies mentioned above, we observed that the incidence of complications and severe complications appeared to be related to the number of surgical cases. This may be due to the higher number of procedures performed at our center, allowing surgeons to gain greater proficiency in this technique, thereby reducing the occurrence of surgical complications.

The results of this study show that there were no significant differences between continuous and interrupted suturing in terms of intraoperative blood loss (31.47 ± 3.99 vs 30.11 ± 4.84, p = 0.18). No Grade C biliary stricture occurred. The incidence of bile leakage was 3.3% in the continuous suturing group and 3.4% in the interrupted suturing group. The bile leakage rate in the continuous suturing group (3.3%) was slightly lower than in the interrupted suturing group (3.4%), with a statistically difference (P = 0.04).

Regarding the convenience of suturing, Wang et al. reported that the operative time for continuous suturing was 121.12 ± 18.2 min [15], Zhou et al.’s study [19] showed that the operative time for continuous suturing was 95.6 ± 10.3 min, suturing time was 9.8 ± 1.3 min, Jiang et al.’s [16] research showed that the operative time for continuous suturing was 82 (65–108) min, Gurusamy et al.’s [20] study showed that for interrupted suturing, the operative time was 95.22 ± 19.35 min, suturing time was 9.66 ± 2.50 min. The results of this study show that there were no significant differences between continuous and interrupted suturing in terms of operative time (65.61 ± 13.68 vs 71.59 ± 18.58, p = 0.12). Compared to other studies, the operative time in this study was shorter, which may be related to the fact that the patients in this study had no obvious jaundice preoperatively and a CBD diameter of ≥ 7 mm. However, in terms of suturing time, the continuous suturing group was significantly shorter than the interrupted suturing group (14.71 ± 2.04 vs 19.45 ± 1.42, P < 0.01), which is consistent with the meta-analysis conclusion by Huang et al. The mechanism may be due to continuous suturing reducing the number of knot tying and instrument exchange time. The results of this study show that there were no significant differences between continuous and interrupted suturing in terms of operative time (65.61 ± 13.68 vs 71.59 ± 18.58, p = 0.12).

Wills VL et al. [21] reported that T-tube placement reduces patients’ quality of life. Existing literature [15,16,17,18,19] primarily focuses on comparing the safety and efficacy of primary closure versus T-tube drainage, with limited evaluation of postoperative quality of life. Therefore, we utilized the GIQLI score to assess patients’ postoperative quality of life. Our results showed that the scores for the continuous and interrupted suturing groups were 132.74 ± 8.25 and 132.06 ± 8.98, respectively, indicating that both groups had a generally satisfactory postoperative quality of life.

This study compares the postoperative outcomes of continuous versus interrupted suturing of the common bile duct (CBD) after laparoscopic CBD exploration (LCBDE) in an East Asian population, providing regional data support for the selection of suturing techniques in LCBDE. The results suggest that for patients with no preoperative jaundice and a CBD diameter ≥ 7 mm, both continuous and interrupted sutures are viable methods for suturing the CBD wall after LCBDE, and both techniques are safe and effective. Continuous suturing can be considered the preferred option to shorten the surgical time. This conclusion has important practical value for optimizing perioperative decision-making and advancing precision hepatobiliary surgery.

This study is a single-center retrospective cohort analysis with a sample size (n = 120) that is relatively large compared to similar studies, but further validation with large multi-center samples is required. Additionally, the postoperative follow-up period for assessing bile duct stenosis was relatively short. Future research should design prospective RCTs, standardize suturing techniques and materials, and extend the follow-up period to clarify long-term outcome differences.

Conclusion

In conclusion, in patients meeting specific criteria, LC + BDE with PCCBD using either continuous or interrupted suturing without biliary drainage is a safe and effective procedure. This technique supports postoperative recovery, enhances postoperative quality of life, and maintains a low incidence of complications. Compared to interrupted suturing, continuous suturing offers greater procedural efficiency.