A Look at the Evolution of Minimally Invasive Surgery for Gallstone Disease

Gallstones, a common digestive disease, are hard deposits that form in the gallbladder or bile ducts. Without surgical intervention, they can cause abdominal pain, fever, jaundice, and repeated episodes may damage liver and gallbladder function. Hepatobiliary surgeons have made decades of refinement in gallstone surgery, long beyond the era of traditional large-incision open surgery. With a relentless pursuit of excellence, surgeons have refined surgical approaches, minimized incisions, and improved every detail, paving a path toward the ultimate in minimally invasive care.

In the past decade, the Department of Hepatobiliary Surgery at Peking University International Hospital has performed over 3,000 gallstone surgeries, with minimally invasive procedures accounting for more than 95%. The steadily increasing rate of minimally invasive surgery reflects surgeons' deep commitment to continuous improvement.

Gallbladder Stone Surgery: From Conventional to Ultra-Minimally Invasive
In cases which require a cholecystectomy, where the gallbladder needs to be removed, surgeons have refined procedures along four main lines: reducing the number and size of incisions, decreasing injury inside the abdominal cavity, simplifying disposable instruments, and speeding up recovery. This has led to a stepwise progression of minimally invasive approaches.

1. Conventional Laparoscopic Cholecystectomy: Surgeons remove the gallbladder with the assistance of a laparoscopic camera. This classic first-generation minimally invasive procedure uses 3–4 small holes (0.5–1 cm each) in the abdominal wall, instead of the old 10+ cm open incision. With a high-definition laparoscopic camera, the surgeon removes the gallbladder from a distance, greatly reducing damage to abdominal muscles and blood vessels. Patients have less pain and a shorter hospital stay. While this became the standard over open surgery, surgeons saw room for further improvement in the number and size of ports (the entry holes).

2. Ultra-Minimally Invasive Laparoscopic Cholecystectomy: Focused on making the incisions even smaller, surgeons reduced the puncture size from 5–10 mm down to just a few millimeters. Using specially modified miniature instruments, and maintaining clear vision and safety, this approach further cuts trauma to the abdominal wall. Patients have even tinier scars, less pain, and can get out of bed sooner. It is a refined upgrade of the conventional laparoscopic method.

Pictured: small incisions from ultra-minimally invasive laparoscopic cholecystectomy 

3. Single-Port or Reduced-Port Laparoscopic Cholecystectomy: This pushes toward 'fewer incisions and nearly scarless.’ A reduced-port procedure uses only 2 holes instead of 3–4. A single-port procedure makes just one small cut hidden inside the natural fold of the belly button (navel), through which all instruments enter the abdomen. Thanks to the belly button's natural crease, the scar is nearly invisible. This technique demands exceptional skill from the surgeon, who must practice for years to avoid instruments getting in the way at a single entry point. It represents a combination of surgical aesthetics and expertise.

Pictured: single port (navel) laparoscopic cholecystectomy

Minimally Invasive Surgery for Bile Duct Stones: Optimizing Drainage Strategies
Bile duct stones are located deep inside the common bile duct, which carries bile from the liver and gallbladder to the small intestine. In the past, open surgery caused significant trauma and required a long period of drainage through a T-tube – a rubber tube shaped like the letter "T" placed in the bile duct, with one end coming out through the skin to drain bile into a bag. This negatively affects a patient’s quality of life. Surgical teams have developed three improved minimally invasive methods, each reducing postoperative trauma further:

1. Conventional Laparoscopic Common Bile Duct Exploration with T-tube Drainage: Using small laparoscopic incisions, the surgeon opens the bile duct, removes stones, and leaves a T-tube connected to an external bag to drain leftover bile and tiny stone fragments. Compared with open surgery, this is already minimally invasive. However, the T-tube must stay in place for several weeks, limiting daily activities and posing infection risks. To overcome this, surgeons developed a new technique called primary closure.

2. Laparoscopic Common Bile Duct Exploration with Primary Closure: Instead of placing a T-tube, the surgeon closes the bile duct with sutures after stone removal. The surgeon uses absorbable sutures to tightly seal the cut in the common bile duct, so there is no external tube or drainage bag. This avoids tube-related infections and dislodgement, and greatly improves the patient's quality of life. However, it requires very precise suturing to prevent bile leakage – a major milestone in refined minimally invasive surgery.

3. Laparoscopic Transcystic Common Bile Duct Exploration: This technique takes the minimally invasive concept to its extreme. It cleverly uses the body's natural passageway – the cystic duct (the small tube connecting the gallbladder to the common bile duct) – instead of cutting the common bile duct directly. Stone-removing instruments are passed through the slender cystic duct into the common bile duct. The entire bile duct wall remains intact with no extra incision, preserving the natural structure to the greatest extent. This reduces surgical trauma to a new low among similar procedures, making it a top-tier minimally invasive solution that surgeons have honed through profound anatomical knowledge.

Surgical Craftsmanship: Driving Minimally Invasive Technology Forward
From multi-port laparoscopy to single-port scarless surgery, from T-tube drainage to primary bile duct closure, from relying on plastic clips to refined freehand knot-tying – each step forward stems from hepatobiliary surgeons' relentless pursuit of less invasive care. The over 95% minimally invasive surgery rate at Peking University International Hospital's Department of Hepatobiliary Surgery is not the end goal. Rather, it should be seen as a milestone achieved by surgeons continuously optimizing every detail while balancing safety and minimally invasive outcomes.

As surgical tools and concepts continue to evolve, minimally invasive gallstone surgery will keep moving toward less trauma, faster recovery, no visible scars, and preservation of organ function. Surgical commitment to excellence will remain the core driving force behind continued breakthroughs in minimally invasive technology.

Hepatobiliary Surgery

The Department of Hepatobiliary Surgery specializes in precise, minimally invasive, and systematic surgical treatment, covering hepatobiliary, pancreatic surgery, portal hypertension surgery, and transplant surgery. Technical specialties include anatomical liver resection, complex biliary tract tumor surgery, minimally invasive treatment for pancreatic malignancies, and orthotopic liver transplantation.

As the core department of Peking University International Hospital's Hepatobiliary and Pancreatic Cancer Multidisciplinary Team (MDT) for hepatobiliary and pancreatic tumors, the division is led by by Professor Zhang Keming, an academic leader graduated from the University of Tokyo. Professor Zhang has assembled an elite medical team comprising young and middle-aged key specialists. Multiple physicians have pursued advanced studies or training at renowned universities in the United States, Japan, and elsewhere.

The department routinely performs minimally invasive surgical treatments for benign and malignant diseases of the liver, biliary tract, pancreas, and spleen, as well as anatomic segmentectomy, radical resection of complex hilar cholangiocarcinoma, surgical transformation of advanced hepatobiliary malignancies, and laparoscopic pancreatoduodenectomy are at a high level.