Laparoscopic transcystic common bile duct exploration in the management of choledocholithiasis

Abstract

Background: Common bile duct (CBD) stones are identified in 10-15% of patients undergoing surgery for symptomatic cholelithiasis. When choledocholithiasis is suspected preoperatively, it is recommended that endoscopic retrograde cholangiography (ERC) be performed, and if the choledocholithiasis is confirmed, the patient should then undergo endoscopic sphincterotomy (ES). When CBD stones are discovered intraoperatively, the surgeon proceeds with laparoscopic common bile duct exploration (LCBDE), converts the case to open CBD exploration and choledocholithotomy, or leaves the stones in place for postoperative ES and stone extraction. We report here our initial results oflaparoscopic transcystic CBD exploration (LTCBDE) in the management of patients with choledocholithiasis. Patients and methods: From October 2009 to June 2012, we performed 320 laparoscopic cholecystectomies for symptomatic gallstone disease at Zagazig University Hospitals. In the present study, intraoperative cholangiography (IOC) was performed in 47 out of 320 (14.7%) patients. It was negative in 5 (10.6%) patients and suggestive ofCBD stones in 42 (89.4%) patients. The incidence of choledocholithiasis in our study was 13.12% (42 from 320 patients). Three patients were converted to open surgery directly when CBD stones were detected, and two patients were referred for postoperative ERCP. Laparoscopic CBD exploration (LCBDE) was attempted in 37 patients. In 7 patients laparoscopic choledochotomy was done. In the remaining 30 patients (71.4%) LTCBDE was performed. Results: LTCBDE was successful in 27 out of 30 patients (90%). In three patients, LTCBDE failed and were converted to open surgery. Causes of failure of TCBDE were numerous stones (> 8) in one patient, impacted stones at distal CBD in another patient and intrahepatic displacement of stones in the third patient. The mean operative time was 110 ± 30 minutes. Postoperative complications included pulmonary atelectasis in two elderly patients, deep vein thrombosis in one patient and ileus in one patient. The overall complication rate was 13.3%. There were no deaths. No bile leak was observed in any of our patients and all were discharged within the first 48 hours. The mean recovery time was 8 days (ranging from 7 to 10 days). Time to return to full physical activity was 14±4 days.Fallow-up for 6 months to 2 years was possible in 26 patients (86.7%), and no residual stones were found in any ofthem. Conclusion: CBD stones still occur in about 10-15% ofpatients undergoing LC. 90% of these patients could be treated successfully using LTCBDE, with no increase in morbidity or mortality; it seems reasonable to remove stones during the laparoscopic procedure to avoid the possibility of postoperative ERCP or conversion to open surgery. The complications, length of hospital stay, and recovery time were similar to outcomes in patients who underwent LC only. We found that multiple or impacted stones are risk factors for conversion to open surgery. The benefits attained by minimally invasive surgery confirm that LTCBDE should become the primary strategy in the vast majority of patients harboring common bile duct stones.