Laparoendoscopic approach to treatment of common bile duct stones.

Abstract

Whereas laparoscopic cholecystectomy represents the gold standard treatment for gallstones, there is no universal consensus on the optimal treatment of common bile duct (CBD) stones. The options available are various: preoperative or postoperative endoscopic retrograde cholangiography and sphincterotomy, laparoscopic transcystic CBD exploration, laparoscopic choledochotomy, and traditional open choledochotomy. A few reports describe intraoperative endoscopic clearance of the CBD. The choice of one of these methods depends on the timing of the detection of CBD stones with regard to the cholecystectomy, the expertise of the surgeon, the technology available, and the wishes of the patient. In the surgical department of the "Ospedale Casa Sollievo della Sofferenza," a large referral medical center in Italy, we perform an intraoperative endoscopic sphincterotomy in the presence of findings suspicious for CBD stones in the course of a laparoscopic cholecystectomy. The procedure is readily available thanks to the nearby presence of a skilled endoscopist and is greatly aided by the insertion of a transcystic guidewire, which makes the papilla easily identifiable by the endoscope for the spincterotomy. We have used the technique successfully in 43 of 45 patients over a 7-year period in an overall caseload of 1775 laparoscopic cholecystectomies, with no complications, minimal added operative time, and no added postoperative hospital stay. The technique allows us to completely and definitively manage CBD stones detected intraoperatively at the time of the performance of the laparoscopic cholecystectomy with no added discomfort to the patient.