Single-center prospective study on triple-port laparoscopic cholecystectomy combined with choledochoscopic common bile duct exploration and primary closure without T-tube drainage for acute abdominal pain

Single-center prospective study on triple-port laparoscopic cholecystectomy combined with choledochoscopic common bile duct exploration and primary closure without T-tube drainage for acute abdominal pain | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Single-center prospective study on triple-port laparoscopic cholecystectomy combined with choledochoscopic common bile duct exploration and primary closure without T-tube drainage for acute abdominal pain Xirang Wang, Jian Kang, Yuxiang Li, Xiaofeng Sun, Jun Zhang, Yunpeng Wu, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6779576/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Jan, 2026 Read the published version in Scientific Reports → Version 1 posted 11 You are reading this latest preprint version Abstract Objective To evaluate the clinical efficacy of laparoscopic common bile duct exploration (LCBDE) combined with choledochoscopy and primary closure without T-tube drainage in managing acute abdominal pain caused by choledocholithiasis (common bile duct stones, CBDS) and cholecystolithiasis with acute cholecystitis. Methods A single-center prospective study was conducted at the Department of General Surgery, Beijing Fengtai Youanmen Hospital, from April 2024 to February 2025. Sixty-one patients with acute abdominal pain due to CBDS and cholecystolithiasis with acute cholecystitis were randomized into two groups: T-tube-free group (n = 35), Triple-port laparoscopic cholecystectomy (LC) + LCBDE with primary closure; T-tube group (n = 26), Four-port LC + LCBDE with T-tube drainage. Perioperative outcomes were compared between the groups. Results Baseline characteristics were comparable (all P > 0.05). The T-tube-free group demonstrated superior outcomes in operative time, intraoperative blood loss, postoperative pain, duration of abdominal drainage, and hospital stay (all P < 0.05). Each group had one case of biliary leakage, both resolved conservatively. No mortality, pancreatitis, conversion to open surgery, residual stones, biliary hemorrhage, or strictures occurred in either group. Conclusion Triple-port LC combined with LCBDE and primary closure without T-tube drainage is safe and feasible for acute abdominal pain. Compared to T-tube drainage, this approach better aligns with the principles of enhanced recovery after surgery (ERAS). Health sciences/Gastroenterology Health sciences/Medical research Choledocholithiasis CBDS Laparoscopy Choledochoscopic exploration T-tube drainage Prospective study Figures Figure 1 Figure 2 Figure 3 Introduction The prevalence of cholecystolithiasis in China has demonstrated a consistent annual increase, with epidemiological data indicating that approximately 20% of adults harbor asymptomatic gallstones [1]. Notably, 85% of CBDS are secondary to gallbladder stones, where stone migration via gallbladder contraction may precipitate acute biliary obstruction. This pathological process can trigger severe complications including acute cholangitis (17.3%), acute pancreatitis (9.6%), and septic shock (3.1%) [2,3]. The surgical management of acute abdominal pain caused by CBDS and cholecystolithiasis with acute cholecystitis has evolved from traditional open procedures to minimally invasive techniques. Within this paradigm shift, the central surgical challenge has become the development of innovative approaches that minimize operative trauma while optimizing postoperative recovery [4,5]. Under the guidance of ERAS principles, our center has observed that while conventional four-port LCBDE with T-tube drainage remains prevalent for acute presentations, the triple-port LCBDE with primary closure remains underutilized in emergency settings. Through strategic optimization of port placement and refined common bile duct (CBD) incision/closure techniques, we have achieved reduced iatrogenic trauma and accelerated postoperative recovery. To rigorously evaluate the safety and feasibility of this approach, we conducted a prospective randomized controlled trial (RCT), the results of which are presented herein. 1 Materials and Methods 1.1 General Data This trial was registered at China's national registry for medical research (Chinese Medical Research Registration and Filing Information System, CMRRFIS), a primary registry in the WHO Registry Network (Registration number: MR-11-24-008651; Date of first registration: 06/03/2024). This prospective randomized controlled study was approved by the Ethics Committee of Beijing Fengtai Youanmen Hospital (Grant No. LL-2024-04) and conducted in accordance with the Helsinki Declaration. Patients or their families signed informed consent forms. Supported by the hospital's research fund (Grant No. KY-2024-04), the study enrolled 61 patients with acute abdomen due to CBDS and cholecystolithiasis with acute cholecystitis from April 2024 to February 2025. Patients were randomly assigned to the T-tube-free group or the T-tube group using Research Randomizer ( http://www.randomizer.org ). Participants, care givers, and those assessing the outcomes were blinded to group assignment. The T-tube-free group (n = 35) underwent triple-port LCBDE with primary closure, versus the T-tube group (n = 26) managed with four-port LCBDE + T-tube placement. Baseline characteristics (gender, age, BMI, symptom duration, laboratory values [TBIL, DBIL, ALP, ALT, AST, AMY, WBC, ALB, CRP, PCT], CBD diameter, pain scores, comorbidities) showed no intergroup differences (all P > 0.05, Table 1 ). 1.2 Surgical Procedure All patients were preoperatively assessed by an anesthesiologist using the American Society of Anesthesiologists (ASA) score. The same surgical team performed all operations, with the chief surgeon positioned at the patient's right head side and the assistant at the right tail side. In the T-tube-free group, a 10-mm umbilical incision (camera port, Port A) was created for CO 2 pneumoperitoneum establishment and trocar insertion. Following diagnostic laparoscopy, two additional ports were placed under direct visualization: A 10-mm epigastric port (Port B) 1 cm below the xiphoid process; A 5-mm right subcostal port (Port C) 2 cm below the costal margin on the midclavicular line (Fig. 1 ). The gallbladder and hepatocystic triangle were carefully exposed. LC was performed adhering strictly to the Critical View of Safety (CVS) criteria (Fig. 2 ). The Calot's triangle was dissected using a combination of sharp and blunt techniques until only the cystic duct and cystic artery were clearly identified, which were then clipped and divided. The gallbladder was dissected from its bed and placed in a disposable retrieval bag, temporarily positioned in the perihepatic space. The CBD was fully mobilized, and a longitudinal incision was made distal to the cystic duct–common hepatic duct confluence using an electrocautery hook in cut mode (power < 45 W). Bile efflux confirmed entry into the lumen. The incision was gently widened using laparoscopic dissectors. A choledochoscope was introduced, revealing CBDS, which were extracted using a disposable stone retrieval basket. Repeat choledochoscopy confirmed clearance of stones from the distal CBD (to the duodenal papilla) and proximal ducts (up to secondary hepatic branches), with no obstructions or masses detected. The CBD incision was closed with a continuous 3 − 0 Polydioxanone (PDO) Barbed Absorbable Suture (stitch interval: 1.0–1.5 mm). A gauze compression test confirmed no bile leakage. The specimen was extracted via Port B. The abdominal cavity was irrigated with warm saline, and a closed-suction drain was placed in the subhepatic space via Port C. In the T-Tube Drainage Group, port positions A (umbilical), B (subxiphoid), and C (right subcostal) mirrored those in the triple-port group, with the addition of port D: 5-mm trocar placed 2 cm below the right costal margin along the anterior axillary line (Fig. 3 ). The assistant utilized Port D to optimize retraction and exposure of Calot's triangle. Following identical choledochoscopic stone extraction as the triple-port group, a T-tube was inserted into the CBD via Port C. A closed-suction drain was positioned in the subhepatic space through Port D. The T-tube suture line was tested for watertight closure by instilling 10 mL of 0.9% sterile saline under direct visualization, with no evidence of extravasation. 1.3 Outcome Measures The following parameters were prospectively recorded and compared between groups. Intraoperative outcomes: Operative time (minutes), Intraoperative blood loss (mL), CBD stone characteristics (number, maximum diameter in mm); Postoperative recovery: Pain scores (Visual Analog Scale,VAS 0–10), Time to first flatus (days), Duration of abdominal drainage (days), Length of hospital stay (days); Complications: Conversion to open surgery, Biliary hemorrhage, Bile leakage, Pancreatitis, Biliary stricture (diagnosed by MRCP at 3-month follow-up). 1.4 Statistical Analysis Statistical analyses were performed using IBM SPSS Statistics 23.0 (IBM Corp., Armonk, NY, USA). Continuous variables were first assessed for normality using the Shapiro-Wilk test. For normally distributed data with homogeneous variance (evaluated by Levene’s test), intergroup comparisons were conducted using independent samples t-test. Non-normally distributed data were analyzed using the Mann-Whitney U test. Categorical variables were compared using the χ² test or Fisher’s exact test, as appropriate. A two-tailed P-value < 0.05 was considered statistically significant. 2 Results The triple-port T-tube-free group demonstrated significantly better outcomes in operative time (shorter), intraoperative blood loss (less), postoperative pain scores (lower), duration of abdominal drainage (shorter), and hospital stay (reduced), with all differences being statistically significant (P 0.05, Table 2 ). Each group had one case of bile leakage, which resolved spontaneously by postoperative day (POD) 3 (drainage fluid became clear and non-bilious), with drains successfully removed on POD4 in both cases. No instances of major intraoperative hemorrhage or conversion to open surgery occurred in either group. All patients had their abdominal drains removed prior to discharge. In the T-tube group, all tubes were removed 6–8 weeks postoperatively. Zero mortality in both cohorts. No cases of pancreatitis, retained stones, biliary hemorrhage, or biliary strictures were observed. Table 1 Preoperative general clinical data of the two groups T-tube-free group(n = 35) T-tube group (n = 26) Statistic P Gender (number ) χ2 = 0.066 0.798 Male 20 14 Female 15 12 Age (years) 63.31 ± 17.02 62.42 ± 13.78 t = 0.219 0.827 BMI (Kg/m 2 ) 24.74 ± 2.38 24.62 ± 3.16 t = 0.180 0.858 Symptom duration(days) 3.00(1.00,5.00) 3.00(2.00,5.00) z =-0.449 0.654 TBIL (µmol/L) 38.37 ± 18.02 45.77 ± 16.31 t =-1.650 0.104 DBIL (µmol/L) 20.86 ± 10.51 24.31 ± 8.17 t =-1.390 0.170 ALP (U/L) 205.51 ± 88.02 221.23 ± 108.72 t =-0.624 0.535 ALT (U/L) 55.80 ± 26.46 54.85 ± 20.17 t = 0.154 0.879 AST (U/L) 61.97 ± 27.98 63.96 ± 29.37 t =-0.269 0.789 AMY (U/L) 60.69 ± 31.15 59.31 ± 29.45 t = 0.175 0.862 WBC (10 9 /L) 11.63 ± 3.94 13.12 ± 3.33 t =-1.555 0.125 ALB (g/L) 39.23 ± 4.63 37.5 ± 4.77 t = 1.424 0.160 CRP (mg/L) 39.91 ± 19.37 46.54 ± 19.81 t =-1.308 0.196 PCT (ng/ml) 2.10 ± 0.92 2.32 ± 0.96 t =-0.874 0.386 CBD diameter (mm) 11.99 ± 2.13 11.50 ± 2.39 t = 0.833 0.408 Preoperative pain scores (NRS) 4.51 ± 2.15 4.23 ± 1.36 t = 0.591 0.557 Comorbidities(number ) χ2 = 1.010 0.315 Yes 17 16 No 18 10 Table 2 Comparison of intraoperative and postoperative indexes between the two groups T-tube-free group(n = 35) T-tube group (n = 26) Statistic P Operative time(min) 88.94 ± 27.68 115.58 ± 32.83 t =-3.432 0.001 Intraoperative blood loss (ml) 10.00(10.00,10.00) 10.00(10.00,20.00) z= -2.069 0.039 Number of CBDS (number) 4.00(3.00,6.00) 4.50(2.00,6.00) z= -0.037 0.971 Maximum diameter of CBDS (mm) 2.67 ± 0.86 2.98 ± 0.51 t =-1.665 0.101 Postoperative pain scores (VAS) 3.53 ± 0.64 3.97 ± 0.57 t =-2.796 0.007 Time to first flatus (days) 1.15 ± 0.35 1.25 ± 0.30 t =-1.105 0.274 Duration of abdominal drainage (days) 3.82 ± 0.42 4.69 ± 0.64 t =-6.426 < 0.001 Length of hospital stay (days) 6.17 ± 0.47 6.82 ± 0.78 t =-4.081 < 0.001 3 Discussion This prospective RCT represents a systematic comparison between triple-port T-tube-free LCBDE and conventional T-tube drainage in the management of acute abdominal pain secondary to CBDS and cholecystolithiasis with acute cholecystitis. Our findings demonstrate that the T-tube-free approach achieved statistically superior outcomes across multiple key parameters: shorter operative time (88.94 ± 27.68 vs. 115.58 ± 32.83 min, P = 0.001), reduced blood loss (median 10.00 [IQR 10.00–10.00] vs. 10.00 [10.00–20.00] mL, P = 0.039), lower surgical site pain scores (3.53 ± 0.64 vs. 3.97 ± 0.57, P = 0.007), earlier drain removal (3.82 ± 0.42 vs. 4.69 ± 0.64 days, P < 0.001), shorter hospitalization (6.17 ± 0.47 vs. 6.82 ± 0.78 days, P < 0.001). These results align with recent technical advancements in LCBDE [ 6 , 5 , 7 , 8 ], particularly regarding trauma minimization through reduced-port strategies. Both groups exhibited comparable complication rates, with one case each of self-limiting bile leakage (resolved by POD4). No instances of: major intraoperative hemorrhage, conversion to laparotomy; mortality, Pancreatitis, retained stones, biliary hemorrhage, or strictures within 3-month follow-up. Endoscopic sphincterotomy (EST), while widely used, carries significant limitations: permanent disruption of sphincteric integrity, post-ERCP pancreatitis rates of 8.3–15.6% [ 9 ], 2.3-fold greater stone recurrence versus surgical interventions [ 10 ]. Percutaneous transhepatic approaches remain niche due to: specialized equipment requirements and procedural complexity. Utilization in acute settings is limited to < 5% of cases [ 11 ]. In contrast, the one-stage LC and LCBDE, which combines gallbladder removal and common bile duct stone extraction, has become the mainstay of treatment. This approach preserves the integrity of the Oddi sphincter and achieves a CBDS clearance rate of over 95% [ 4 , 6 ]. This study demonstrated excellent clinical outcomes with minimal complications (3.3% bile leak rate, no major adverse events), attributable to three optimized technical approaches. First, the combination of reverse Trendelenburg positioning with left lateral tilt and strategically placed high subxiphoid ports enabled gravity-assisted displacement of the transverse colon and omentum, while allowing instrument-leveraged liver retraction for optimal Calot's triangle exposure. Second, our strict adherence to the "cold-cutting" principle [ 7 ] was critical-using electrocautery in cut mode exclusively (< 45W) until initial bile flow visualization, followed by meticulous blunt dilation of the choledochotomy site, significantly reduced thermal injury risks. Third, Continuous biliary closure using 3 − 0 polydioxanone (PDO) barbed absorbable suture with meticulously maintained 1.0-1.5 mm stitch intervals achieved an exemplary postoperative bile leakage rate of 3.3% - a statistically and clinically significant improvement over the 7.1–12.5% range reported in contemporary literature [ 3 , 4 ]. Of particular clinical importance, preoperative MRCP evaluation proved essential for patient, as narrow bile ducts (≤ 1cm diameter) demonstrated higher complication rates, with literature reporting 18.4% 5-year stricture risk in sub-8mm ducts undergoing primary closure [ 3 , 7 ]. The triple-port laparoscopic approach combining cholecystectomy and T-tube-free choledochoscopic common bile duct exploration demonstrates favorable short-term outcomes in patients with acute abdominal pain secondary to CBDS and cholecystolithiasis with acute cholecystitis, establishing its clinical safety and feasibility for broader adoption. However, this study's limitations—particularly the modest sample size (n = 61) and restricted 3-month follow-up period—necessitate validation through multicenter RCTs to assess long-term efficacy and rare complication risks. Abbreviations LCBDE: Laparoscopic common bile duct exploration; CBDS: common bile duct stones; LC: Laparoscopic cholecystectomy; ERAS: Enhanced recovery after surgery; CBD: common bile duct; RCT: randomized controlled trial; ASA: American Society of Anesthesiologists; BMI: Body Mass Index; CVS: Critical View of Safety; MRCP: Magnetic Resonance Cholangiopancreatography; POD: postoperative day; EST: Endoscopic sphincterotomy; ERCP: Endoscopic Retrograde Cholangiopancreatography. Declarations Acknowledgements Not applicable. Authors’ contributions The manuscript has been read and approved by all the authors; the requirements for authorship have been met; each author believes that the manuscript represents honest work. XRW conducted the literature search, analyzed the data, and wrote the manuscript. YXL and JK provided guidance. XFS, JZ, YPW, HHT, LW, RZR, MW, KL and ZBcollected the data. All authors read and approved the final manuscript. Funding This study was supported by the Institutional Research Fund of [Beijing Fengtai Youanmen Hospital] (Grant No. KY-2024-04). Availability of data and materials All data generated during this study are included in this published article. Further minor datasets are available from the corresponding author on reasonable request. Ethics approval and consent to participate This study was conducted in accordance with the ethical standards of the Helsinki Declaration and its amendments. The study protocol was approved by the Ethics Committee of [Beijing Fengtai Youanmen Hospital] (Grant No. LL-2024-04). All patients or their legal guardians provided written informed consent prior to participation in the study. Consent for publication Obtained. Competing of interests The authors declare that they have no competing interests. Author details 1 Department of General Surgery, Beijing Fengtai Youanmen Hospital, Beijing 100069, China. 2 Department of General Surgery, Beijing Huimin Hospital, Beijing 100054, China. *Correspondence: Jian Kang 2* [email protected] 2 Department of General Surgery, Beijing Huimin Hospital, Beijing 100054, China. Yuxiang Li 1* [email protected] 1 Department of General Surgery, Beijing Fengtai Youanmen Hospital, Beijing 100069, China. References Costanzo ML, D'Andrea V, Lauro A, Bellini MI. Acute Cholecystitis from Biliary Lithiasis: Diagnosis, Management and Treatment. Antibiotics (Basel). 2023;12(3):482. Shabanzadeh DM, Christensen DW, Ewertsen C, et al. National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society. Scand J Surg. 2022;111(3):11-30. Fugazzola P, Cobianchi L, Dal Mas F, et al. Prospective validation of the Israeli Score for the prediction of common bile duct stones in patients with acute calculous cholecystitis. Surg Endosc. 2023;37(11):8562-8569. Chaouch MA, Ben Jemia S, Krimi B, et al. Meta-analysis of randomized controlled trials comparing single-stage laparoscopic versus two-stage endoscopic management followed by laparoscopic cholecystectomy of preoperatively diagnosed common bile duct stones. Medicine (Baltimore). 2025;104(11):e41902. Liu J, Duan X. Sequential comparison of single-stage laparoscopic common bile duct exploration combined with cholecystectomy. Updates Surg. Published online April 28, 2025. Zhu J, Wang G, Xie B, Jiang Z, Xiao W, Li Y. Minimally invasive management of concomitant gallstones and common bile duct stones: an updated network meta-analysis of randomized controlled trials. Surg Endosc. 2023;37(3):1683-1693. Zhang RH, Wang XN, Ma YF, et al. Usefulness of intraoperative choledochoscopy in laparoscopic subtotal cholecystectomy for severe cholecystitis. Ann Hepatobiliary Pancreat Surg. Published online April 16, 2025. Xirang Wang, Yuxiang Li, Jian Kang, et al. Clinical Effect Analysis of Three-Port Laparoscopic and Choledochoscopic Common Bile Duct Exploration without T-Tube in the Treatment of Emergency Cholecystolithiasis Combined with Common Bile Duct Stones. Human Biology. 2025;95(1):1010-1014. Wang L, Chen Z. Comparison of Laparoscopic Common Bile Duct Exploration and Endoscopic Retrograde Cholangiopancreatography in the Treatment of Bile Duct Stones and Analysis of Risk Factors for Postoperative Acute Pancreatitis. Altern Ther Health Med. 2023;29(6):358-363. Liu F, Ye L, Wang Y, et al. Short-Term Efficacy of LCBDE+LC Versus ERCP/EST+LC in the Treatment of Cholelithiasis Combined with Common Bile Duct Stones: A Retrospective Cohort Study. J Laparoendosc Adv Surg Tech A. 2025;35(2):145-151. Kaneta A, Sasada H, Matsumoto T, Sakai T, Sato S, Hara T. Efficacy of endoscopic gallbladder drainage in patients with acute cholecystitis. BMC Surg. 2022;22(1):224. Published 2022 Jun 11. Additional Declarations No competing interests reported. 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14:04:32","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":58994,"visible":true,"origin":"","legend":"","description":"","filename":"2d1a56bb55934dde9077e882532adb7d1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-6779576/v1/9b6b3c33faaf9631a03d5207.xml"},{"id":94409405,"identity":"372ea24f-4fc0-4432-a33e-504904e10161","added_by":"auto","created_at":"2025-10-27 14:04:06","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":68072,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-6779576/v1/db2bffdc729b92f0ad824d2d.html"},{"id":94410373,"identity":"c73b1edb-25aa-4b8c-be9e-5c93b4333aeb","added_by":"auto","created_at":"2025-10-27 14:04:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":283483,"visible":true,"origin":"","legend":"\u003cp\u003eStandard port configuration for T-tube-free group\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6779576/v1/2e244cf3ac7cadf3141cff70.png"},{"id":94410203,"identity":"ccd036bc-da80-4992-9980-889004f708a9","added_by":"auto","created_at":"2025-10-27 14:04:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":245054,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative CVS criteria\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6779576/v1/621b8e2cb5fa40dd175a70dc.png"},{"id":94409375,"identity":"79e874f7-465f-43a3-9914-64d9d4d4c708","added_by":"auto","created_at":"2025-10-27 14:04:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":256903,"visible":true,"origin":"","legend":"\u003cp\u003eStandard port configuration for T-tube drainage group\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6779576/v1/9cfc32b6ee8e63429082eeca.png"},{"id":101151841,"identity":"8bc87e6e-6343-4a90-81ea-aebca3283b6f","added_by":"auto","created_at":"2026-01-26 16:06:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1697179,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6779576/v1/25676960-c4ef-48d9-97dd-638c64b66c09.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Single-center prospective study on triple-port laparoscopic cholecystectomy combined with choledochoscopic common bile duct exploration and primary closure without T-tube drainage for acute abdominal pain","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe prevalence of cholecystolithiasis in China has demonstrated a consistent annual increase, with epidemiological data indicating that approximately 20% of adults harbor asymptomatic gallstones [1]. Notably, 85% of CBDS are secondary to gallbladder stones, where stone migration via gallbladder contraction may precipitate acute biliary obstruction. This pathological process can trigger severe complications including acute cholangitis (17.3%), acute pancreatitis (9.6%), and septic shock (3.1%) [2,3]. The surgical management of acute abdominal pain caused by CBDS and cholecystolithiasis with acute cholecystitis has evolved from traditional open procedures to minimally invasive techniques. Within this paradigm shift, the central surgical challenge has become the development of innovative approaches that minimize operative trauma while optimizing postoperative recovery [4,5]. Under the guidance of ERAS principles, our center has observed that while conventional four-port LCBDE with T-tube drainage remains prevalent for acute presentations, the triple-port LCBDE with primary closure remains underutilized in emergency settings. Through strategic optimization of port placement and refined common bile duct (CBD) incision/closure techniques, we have achieved reduced iatrogenic trauma and accelerated postoperative recovery. To rigorously evaluate the safety and feasibility of this approach, we conducted a prospective randomized controlled trial (RCT), the results of which are presented herein.\u003c/p\u003e"},{"header":"1 Materials and Methods","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003e1.1 General Data\u003c/h2\u003e\u003cp\u003eThis trial was registered at China's national registry for medical research (Chinese Medical Research Registration and Filing Information System, CMRRFIS), a primary registry in the WHO Registry Network (Registration number: MR-11-24-008651; Date of first registration: 06/03/2024). This prospective randomized controlled study was approved by the Ethics Committee of Beijing Fengtai Youanmen Hospital (Grant No. LL-2024-04) and conducted in accordance with the Helsinki Declaration. Patients or their families signed informed consent forms. Supported by the hospital's research fund (Grant No. KY-2024-04), the study enrolled 61 patients with acute abdomen due to CBDS and cholecystolithiasis with acute cholecystitis from April 2024 to February 2025. Patients were randomly assigned to the T-tube-free group or the T-tube group using Research Randomizer (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.randomizer.org\u003c/span\u003e\u003cspan address=\"http://www.randomizer.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Participants, care givers, and those assessing the outcomes were blinded to group assignment. The T-tube-free group (n\u0026thinsp;=\u0026thinsp;35) underwent triple-port LCBDE with primary closure, versus the T-tube group (n\u0026thinsp;=\u0026thinsp;26) managed with four-port LCBDE\u0026thinsp;+\u0026thinsp;T-tube placement. Baseline characteristics (gender, age, BMI, symptom duration, laboratory values [TBIL, DBIL, ALP, ALT, AST, AMY, WBC, ALB, CRP, PCT], CBD diameter, pain scores, comorbidities) showed no intergroup differences (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e1.2 Surgical Procedure\u003c/h2\u003e\u003cp\u003eAll patients were preoperatively assessed by an anesthesiologist using the American Society of Anesthesiologists (ASA) score. The same surgical team performed all operations, with the chief surgeon positioned at the patient's right head side and the assistant at the right tail side.\u003c/p\u003e\u003cp\u003eIn the T-tube-free group, a 10-mm umbilical incision (camera port, Port A) was created for CO\u003csub\u003e2\u003c/sub\u003e pneumoperitoneum establishment and trocar insertion. Following diagnostic laparoscopy, two additional ports were placed under direct visualization: A 10-mm epigastric port (Port B) 1 cm below the xiphoid process; A 5-mm right subcostal port (Port C) 2 cm below the costal margin on the midclavicular line (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The gallbladder and hepatocystic triangle were carefully exposed. LC was performed adhering strictly to the Critical View of Safety (CVS) criteria (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The Calot's triangle was dissected using a combination of sharp and blunt techniques until only the cystic duct and cystic artery were clearly identified, which were then clipped and divided. The gallbladder was dissected from its bed and placed in a disposable retrieval bag, temporarily positioned in the perihepatic space. The CBD was fully mobilized, and a longitudinal incision was made distal to the cystic duct\u0026ndash;common hepatic duct confluence using an electrocautery hook in cut mode (power\u0026thinsp;\u0026lt;\u0026thinsp;45 W). Bile efflux confirmed entry into the lumen. The incision was gently widened using laparoscopic dissectors. A choledochoscope was introduced, revealing CBDS, which were extracted using a disposable stone retrieval basket. Repeat choledochoscopy confirmed clearance of stones from the distal CBD (to the duodenal papilla) and proximal ducts (up to secondary hepatic branches), with no obstructions or masses detected. The CBD incision was closed with a continuous 3\u0026thinsp;\u0026minus;\u0026thinsp;0 Polydioxanone (PDO) Barbed Absorbable Suture (stitch interval: 1.0\u0026ndash;1.5 mm). A gauze compression test confirmed no bile leakage. The specimen was extracted via Port B. The abdominal cavity was irrigated with warm saline, and a closed-suction drain was placed in the subhepatic space via Port C.\u003c/p\u003e\u003cp\u003eIn the T-Tube Drainage Group, port positions A (umbilical), B (subxiphoid), and C (right subcostal) mirrored those in the triple-port group, with the addition of port D: 5-mm trocar placed 2 cm below the right costal margin along the anterior axillary line (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The assistant utilized Port D to optimize retraction and exposure of Calot's triangle. Following identical choledochoscopic stone extraction as the triple-port group, a T-tube was inserted into the CBD via Port C. A closed-suction drain was positioned in the subhepatic space through Port D. The T-tube suture line was tested for watertight closure by instilling 10 mL of 0.9% sterile saline under direct visualization, with no evidence of extravasation.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e1.3 Outcome Measures\u003c/h2\u003e\u003cp\u003eThe following parameters were prospectively recorded and compared between groups. Intraoperative outcomes: Operative time (minutes), Intraoperative blood loss (mL), CBD stone characteristics (number, maximum diameter in mm); Postoperative recovery: Pain scores (Visual Analog Scale,VAS 0\u0026ndash;10), Time to first flatus (days), Duration of abdominal drainage (days), Length of hospital stay (days); Complications: Conversion to open surgery, Biliary hemorrhage, Bile leakage, Pancreatitis, Biliary stricture (diagnosed by MRCP at 3-month follow-up).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e1.4 Statistical Analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics 23.0 (IBM Corp., Armonk, NY, USA). Continuous variables were first assessed for normality using the Shapiro-Wilk test. For normally distributed data with homogeneous variance (evaluated by Levene\u0026rsquo;s test), intergroup comparisons were conducted using independent samples t-test. Non-normally distributed data were analyzed using the Mann-Whitney U test. Categorical variables were compared using the χ\u0026sup2; test or Fisher\u0026rsquo;s exact test, as appropriate. A two-tailed P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"2 Results","content":"\u003cp\u003eThe triple-port T-tube-free group demonstrated significantly better outcomes in operative time (shorter), intraoperative blood loss (less), postoperative pain scores (lower), duration of abdominal drainage (shorter), and hospital stay (reduced), with all differences being statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, there were no significant intergroup differences in the number of CBDS, maximum stone diameter, or time to first flatus (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Each group had one case of bile leakage, which resolved spontaneously by postoperative day (POD) 3 (drainage fluid became clear and non-bilious), with drains successfully removed on POD4 in both cases. No instances of major intraoperative hemorrhage or conversion to open surgery occurred in either group. All patients had their abdominal drains removed prior to discharge. In the T-tube group, all tubes were removed 6\u0026ndash;8 weeks postoperatively. Zero mortality in both cohorts. No cases of pancreatitis, retained stones, biliary hemorrhage, or biliary strictures were observed.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePreoperative general clinical data of the two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT-tube-free group(n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eT-tube group (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStatistic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (number\u003c/p\u003e\u003cp\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eχ2\u0026thinsp;=\u0026thinsp;0.066\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.798\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63.31\u0026thinsp;\u0026plusmn;\u0026thinsp;17.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.42\u0026thinsp;\u0026plusmn;\u0026thinsp;13.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.219\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.827\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24.74\u0026thinsp;\u0026plusmn;\u0026thinsp;2.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.62\u0026thinsp;\u0026plusmn;\u0026thinsp;3.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.858\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptom duration(days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.00(1.00,5.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.00(2.00,5.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ez\u003c/em\u003e=-0.449\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.654\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTBIL (\u0026micro;mol/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38.37\u0026thinsp;\u0026plusmn;\u0026thinsp;18.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45.77\u0026thinsp;\u0026plusmn;\u0026thinsp;16.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-1.650\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.104\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDBIL (\u0026micro;mol/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.86\u0026thinsp;\u0026plusmn;\u0026thinsp;10.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.31\u0026thinsp;\u0026plusmn;\u0026thinsp;8.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-1.390\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.170\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eALP (U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e205.51\u0026thinsp;\u0026plusmn;\u0026thinsp;88.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e221.23\u0026thinsp;\u0026plusmn;\u0026thinsp;108.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-0.624\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.535\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eALT (U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55.80\u0026thinsp;\u0026plusmn;\u0026thinsp;26.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.85\u0026thinsp;\u0026plusmn;\u0026thinsp;20.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.154\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.879\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAST (U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61.97\u0026thinsp;\u0026plusmn;\u0026thinsp;27.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.96\u0026thinsp;\u0026plusmn;\u0026thinsp;29.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-0.269\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.789\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAMY (U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60.69\u0026thinsp;\u0026plusmn;\u0026thinsp;31.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59.31\u0026thinsp;\u0026plusmn;\u0026thinsp;29.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.862\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWBC (10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.63\u0026thinsp;\u0026plusmn;\u0026thinsp;3.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.12\u0026thinsp;\u0026plusmn;\u0026thinsp;3.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-1.555\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.125\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eALB (g/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39.23\u0026thinsp;\u0026plusmn;\u0026thinsp;4.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.424\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.160\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCRP (mg/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39.91\u0026thinsp;\u0026plusmn;\u0026thinsp;19.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46.54\u0026thinsp;\u0026plusmn;\u0026thinsp;19.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-1.308\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.196\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePCT (ng/ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-0.874\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.386\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCBD diameter (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.99\u0026thinsp;\u0026plusmn;\u0026thinsp;2.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.833\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.408\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative pain scores (NRS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.51\u0026thinsp;\u0026plusmn;\u0026thinsp;2.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.591\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.557\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidities(number\u003c/p\u003e\u003cp\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eχ2\u0026thinsp;=\u0026thinsp;1.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.315\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of intraoperative and postoperative indexes between the two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT-tube-free group(n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eT-tube group (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStatistic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time(min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88.94\u0026thinsp;\u0026plusmn;\u0026thinsp;27.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e115.58\u0026thinsp;\u0026plusmn;\u0026thinsp;32.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-3.432\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraoperative blood loss (ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.00(10.00,10.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.00(10.00,20.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ez=\u003c/em\u003e-2.069\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.039\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of CBDS (number)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.00(3.00,6.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.50(2.00,6.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ez=\u003c/em\u003e-0.037\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.971\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaximum diameter of CBDS (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-1.665\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.101\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative pain scores (VAS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-2.796\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime to first flatus (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-1.105\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.274\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of abdominal drainage (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-6.426\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength of hospital stay (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e=-4.081\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"3 Discussion","content":"\u003cp\u003eThis prospective RCT represents a systematic comparison between triple-port T-tube-free LCBDE and conventional T-tube drainage in the management of acute abdominal pain secondary to CBDS and cholecystolithiasis with acute cholecystitis. Our findings demonstrate that the T-tube-free approach achieved statistically superior outcomes across multiple key parameters: shorter operative time (88.94\u0026thinsp;\u0026plusmn;\u0026thinsp;27.68 vs. 115.58\u0026thinsp;\u0026plusmn;\u0026thinsp;32.83 min, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), reduced blood loss (median 10.00 [IQR 10.00\u0026ndash;10.00] vs. 10.00 [10.00\u0026ndash;20.00] mL, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.039), lower surgical site pain scores (3.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64 vs. 3.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007), earlier drain removal (3.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42 vs. 4.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64 days, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), shorter hospitalization (6.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47 vs. 6.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78 days, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These results align with recent technical advancements in LCBDE [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], particularly regarding trauma minimization through reduced-port strategies. Both groups exhibited comparable complication rates, with one case each of self-limiting bile leakage (resolved by POD4). No instances of: major intraoperative hemorrhage, conversion to laparotomy; mortality, Pancreatitis, retained stones, biliary hemorrhage, or strictures within 3-month follow-up.\u003c/p\u003e\u003cp\u003eEndoscopic sphincterotomy (EST), while widely used, carries significant limitations: permanent disruption of sphincteric integrity, post-ERCP pancreatitis rates of 8.3\u0026ndash;15.6% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], 2.3-fold greater stone recurrence versus surgical interventions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Percutaneous transhepatic approaches remain niche due to: specialized equipment requirements and procedural complexity. Utilization in acute settings is limited to \u0026lt;\u0026thinsp;5% of cases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In contrast, the one-stage LC and LCBDE, which combines gallbladder removal and common bile duct stone extraction, has become the mainstay of treatment. This approach preserves the integrity of the Oddi sphincter and achieves a CBDS clearance rate of over 95% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study demonstrated excellent clinical outcomes with minimal complications (3.3% bile leak rate, no major adverse events), attributable to three optimized technical approaches. First, the combination of reverse Trendelenburg positioning with left lateral tilt and strategically placed high subxiphoid ports enabled gravity-assisted displacement of the transverse colon and omentum, while allowing instrument-leveraged liver retraction for optimal Calot's triangle exposure. Second, our strict adherence to the \"cold-cutting\" principle [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] was critical-using electrocautery in cut mode exclusively (\u0026lt;\u0026thinsp;45W) until initial bile flow visualization, followed by meticulous blunt dilation of the choledochotomy site, significantly reduced thermal injury risks. Third, Continuous biliary closure using 3\u0026thinsp;\u0026minus;\u0026thinsp;0 polydioxanone (PDO) barbed absorbable suture with meticulously maintained 1.0-1.5 mm stitch intervals achieved an exemplary postoperative bile leakage rate of 3.3% - a statistically and clinically significant improvement over the 7.1\u0026ndash;12.5% range reported in contemporary literature [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Of particular clinical importance, preoperative MRCP evaluation proved essential for patient, as narrow bile ducts (\u0026le;\u0026thinsp;1cm diameter) demonstrated higher complication rates, with literature reporting 18.4% 5-year stricture risk in sub-8mm ducts undergoing primary closure [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe triple-port laparoscopic approach combining cholecystectomy and T-tube-free choledochoscopic common bile duct exploration demonstrates favorable short-term outcomes in patients with acute abdominal pain secondary to CBDS and cholecystolithiasis with acute cholecystitis, establishing its clinical safety and feasibility for broader adoption. However, this study's limitations\u0026mdash;particularly the modest sample size (n\u0026thinsp;=\u0026thinsp;61) and restricted 3-month follow-up period\u0026mdash;necessitate validation through multicenter RCTs to assess long-term efficacy and rare complication risks.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLCBDE: Laparoscopic common bile duct exploration; CBDS: common bile duct stones; LC: Laparoscopic cholecystectomy; ERAS: Enhanced recovery after surgery; CBD: common bile duct; RCT: randomized controlled trial; ASA: American Society of Anesthesiologists; BMI: Body Mass Index; CVS: Critical View of Safety; MRCP: Magnetic Resonance Cholangiopancreatography; POD: postoperative day; EST: Endoscopic sphincterotomy; ERCP: Endoscopic Retrograde Cholangiopancreatography.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe manuscript has been read and approved by all the authors; the requirements for authorship have been met; each author believes that the manuscript represents honest work. XRW conducted the literature search, analyzed the data, and wrote the manuscript. YXL and JK provided guidance. XFS, JZ, YPW, HHT, LW, RZR, MW, KL and ZBcollected the data. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Institutional Research Fund of [Beijing Fengtai Youanmen Hospital] (Grant No. KY-2024-04).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated during this study are included in this published article. Further minor datasets are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical standards of the Helsinki Declaration and its amendments. The study protocol was approved by the Ethics Committee of [Beijing Fengtai Youanmen Hospital] (Grant No. LL-2024-04). All patients or their legal guardians provided written informed consent prior to participation in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eObtained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting of interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of General Surgery, Beijing Fengtai Youanmen Hospital, Beijing 100069, China. \u003csup\u003e2\u003c/sup\u003eDepartment of General Surgery, Beijing Huimin Hospital, Beijing 100054, China.\u003c/p\u003e\n\u003cp\u003e*Correspondence:\u003c/p\u003e\n\u003cp\u003eJian Kang\u003csup\u003e2*\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;[email protected]\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eDepartment of General Surgery, Beijing Huimin Hospital, Beijing 100054, China.\u003c/p\u003e\n\u003cp\u003eYuxiang Li\u003csup\u003e1*\u003c/sup\u003e\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of General Surgery, Beijing Fengtai Youanmen Hospital, Beijing 100069, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCostanzo ML, D\u0026apos;Andrea V, Lauro A, Bellini MI. Acute Cholecystitis from Biliary Lithiasis: Diagnosis, Management and Treatment. Antibiotics (Basel). 2023;12(3):482. \u003c/li\u003e\n\u003cli\u003eShabanzadeh DM, Christensen DW, Ewertsen C, et al. National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society. Scand J Surg. 2022;111(3):11-30.\u003c/li\u003e\n\u003cli\u003eFugazzola P, Cobianchi L, Dal Mas F, et al. Prospective validation of the Israeli Score for the prediction of common bile duct stones in patients with acute calculous cholecystitis. Surg Endosc. 2023;37(11):8562-8569.\u003c/li\u003e\n\u003cli\u003eChaouch MA, Ben Jemia S, Krimi B, et al. Meta-analysis of randomized controlled trials comparing single-stage laparoscopic versus two-stage endoscopic management followed by laparoscopic cholecystectomy of preoperatively diagnosed common bile duct stones. Medicine (Baltimore). 2025;104(11):e41902.\u003c/li\u003e\n\u003cli\u003eLiu J, Duan X. Sequential comparison of single-stage laparoscopic common bile duct exploration combined with cholecystectomy. Updates Surg. Published online April 28, 2025.\u003c/li\u003e\n\u003cli\u003eZhu J, Wang G, Xie B, Jiang Z, Xiao W, Li Y. Minimally invasive management of concomitant gallstones and common bile duct stones: an updated network meta-analysis of randomized controlled trials. Surg Endosc. 2023;37(3):1683-1693.\u003c/li\u003e\n\u003cli\u003eZhang RH, Wang XN, Ma YF, et al. Usefulness of intraoperative choledochoscopy in laparoscopic subtotal cholecystectomy for severe cholecystitis. Ann Hepatobiliary Pancreat Surg. Published online April 16, 2025.\u003c/li\u003e\n\u003cli\u003eXirang Wang, Yuxiang Li, Jian Kang, et al. Clinical Effect Analysis of Three-Port Laparoscopic and Choledochoscopic Common Bile Duct Exploration without T-Tube in the Treatment of Emergency Cholecystolithiasis Combined with Common Bile Duct Stones. Human Biology. 2025;95(1):1010-1014.\u003c/li\u003e\n\u003cli\u003eWang L, Chen Z. Comparison of Laparoscopic Common Bile Duct Exploration and Endoscopic Retrograde Cholangiopancreatography in the Treatment of Bile Duct Stones and Analysis of Risk Factors for Postoperative Acute Pancreatitis. Altern Ther Health Med. 2023;29(6):358-363. \u003c/li\u003e\n\u003cli\u003eLiu F, Ye L, Wang Y, et al. Short-Term Efficacy of LCBDE+LC Versus ERCP/EST+LC in the Treatment of Cholelithiasis Combined with Common Bile Duct Stones: A Retrospective Cohort Study. J Laparoendosc Adv Surg Tech A. 2025;35(2):145-151.\u003c/li\u003e\n\u003cli\u003eKaneta A, Sasada H, Matsumoto T, Sakai T, Sato S, Hara T. Efficacy of endoscopic gallbladder drainage in patients with acute cholecystitis. BMC Surg. 2022;22(1):224. Published 2022 Jun 11.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Choledocholithiasis, CBDS, Laparoscopy, Choledochoscopic exploration, T-tube drainage, Prospective study","lastPublishedDoi":"10.21203/rs.3.rs-6779576/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6779576/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo evaluate the clinical efficacy of laparoscopic common bile duct exploration (LCBDE) combined with choledochoscopy and primary closure without T-tube drainage in managing acute abdominal pain caused by choledocholithiasis (common bile duct stones, CBDS) and cholecystolithiasis with acute cholecystitis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA single-center prospective study was conducted at the Department of General Surgery, Beijing Fengtai Youanmen Hospital, from April 2024 to February 2025. Sixty-one patients with acute abdominal pain due to CBDS and cholecystolithiasis with acute cholecystitis were randomized into two groups: T-tube-free group (n\u0026thinsp;=\u0026thinsp;35), Triple-port laparoscopic cholecystectomy (LC)\u0026thinsp;+\u0026thinsp;LCBDE with primary closure; T-tube group (n\u0026thinsp;=\u0026thinsp;26), Four-port LC\u0026thinsp;+\u0026thinsp;LCBDE with T-tube drainage. Perioperative outcomes were compared between the groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eBaseline characteristics were comparable (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The T-tube-free group demonstrated superior outcomes in operative time, intraoperative blood loss, postoperative pain, duration of abdominal drainage, and hospital stay (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Each group had one case of biliary leakage, both resolved conservatively. No mortality, pancreatitis, conversion to open surgery, residual stones, biliary hemorrhage, or strictures occurred in either group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eTriple-port LC combined with LCBDE and primary closure without T-tube drainage is safe and feasible for acute abdominal pain. Compared to T-tube drainage, this approach better aligns with the principles of enhanced recovery after surgery (ERAS).\u003c/p\u003e","manuscriptTitle":"Single-center prospective study on triple-port laparoscopic cholecystectomy combined with choledochoscopic common bile duct exploration and primary closure without T-tube drainage for acute abdominal pain","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-26 13:26:16","doi":"10.21203/rs.3.rs-6779576/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-02T11:51:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-30T08:36:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294533263532752709282003123775833887614","date":"2025-11-10T21:09:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306552467587693569227595887181247573129","date":"2025-11-10T09:51:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T17:55:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"132068353562222639526269619627345461892","date":"2025-10-14T19:27:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-12T19:24:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-07T17:47:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-06T10:23:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-05T02:37:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-06-05T02:34:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eced8c62-b7da-4b10-a9be-e324073f74d4","owner":[],"postedDate":"October 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":56731603,"name":"Health sciences/Gastroenterology"},{"id":56731604,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-01-26T16:02:56+00:00","versionOfRecord":{"articleIdentity":"rs-6779576","link":"https://doi.org/10.1038/s41598-026-37034-8","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-01-22 15:58:14","publishedOnDateReadable":"January 22nd, 2026"},"versionCreatedAt":"2025-10-26 13:26:16","video":"","vorDoi":"10.1038/s41598-026-37034-8","vorDoiUrl":"https://doi.org/10.1038/s41598-026-37034-8","workflowStages":[]},"version":"v1","identity":"rs-6779576","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6779576","identity":"rs-6779576","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}