Laparoscopic Choledochotomy Research Articles

Cystic duct dilation during laparoscopic transcystic common bile duct exploration

Successful laparoscopic common bile duct exploration (CBDE) is being reported with increasing frequency. Three techniques for accessing common duct stones laparoscopically have been described: (1) laparoscopic choledochotomy, stone extraction and T-tube placement; (2) endoscopic retrograde sphincterotomy to remove common bile duct stones in conjunction with laparoscopic cholecystectomy; and (3) laparoscopic transcystic CBDE. From the viewpoint of preservation of papillary function, shorter hospitalization, reduction of pain, and faster patient recovery, the last method is superior to the former two. In this procedure, the cystic duct should be initially dilated widely, for passage of a flexible small choledochoscope. Here we report a safe and effective technique for dilation of the cystic duct.

Results of the routine use of a modified endoprosthesis to drain the common bile duct after laparoscopic choledochotomy.

One hundred eighty-one patients were submitted to laparoscopic common bile duct exploration. A transcystic approach was used in 147 patients, choledochotomy in 14, and both in 20. The indications to perform a choledochotomy included stones larger than 20 mm, stones proximal to the cystic duct entrance, and cases in which the transcystic duct approach proved impossible or unsuccessful. The common bile duct was drained by a T-tube in four patients, by laparoscopic sphincterotomy in one, by laparoscopic choledochoduodenostomy in one, and by a 10 Fr endoprosthesis in 28. The stent placement was technically feasible in all patients but one. The biliary drainage was adequate. Mean hospital stay was 2.1 days. Complication was limited to one umbilical infection and one self-limited biliary leak. The procedure proved to be technically simple, safe, and efficient, and resulted in a low morbidity rate and short hospital stay.

Laparoscopic Choledochotomy for Treatment of Common Bile Duct Stones

Laparoscopic Choledochotomy for Treatment of Common Bile Duct Stones

Laparoscopic endobiliary stenting as an adjunct to common bile duct exploration.

The management of common bile duct stones (CBDS) in the era of operative laparoscopy is evolving. Several minimally invasive techniques to remove CBDS have been described, including preoperative endoscopic retrograde cholangiopancreatography (ERCP), postoperative ERCP, lithotripsy, laparoscopic transcystic common bile duct exploration, and laparoscopic choledochotomy with common bile duct exploration (CBDE). Because of the risks and limitations of these procedures, we utilize laparoscopically placed endobiliary stents as an adjunct to CBDE. Sixteen patients underwent laparoscopic common bile duct exploration (LCBDE) by either choledochotomy or the transcystic technique with placement of endobiliary stents. These patients were identified during laparoscopic cholecystectomy as having occult choledocholithiasis, using routine dynamic intraoperative cholangiography. CBDS were successfully removed in all patients as demonstrated by completion cholangiography and intraoperative choledochoscopy. Eighty percent of patients were discharged the following day; the first three patients in this series were observed for 48 h prior to discharge. No patient required T-tube placement and closed suction drains were removed the morning after surgery. Stents were removed endoscopically at 1 month. Six- to 30-month follow-up demonstrates no complications to date. Laparoscopic endobiliary stenting reduces operative morbidity, eliminates the complications of T-tubes, and allows patients to return to unrestricted activity quickly. We recommend laparoscopically placed endobiliary stents in patients undergoing LCBDE.

New non-invasive technique of laparoscopic choledochotomy using abdominal wall lifting method and primary closure

New non-invasive technique of laparoscopic choledochotomy using abdominal wall lifting method and primary closure

Follow-up of 161 unselected consecutive patients treated laparoscopically for common bile duct stones.

Aim was to study the incidence of recurrent ductal stones and of biliary strictures at follow-up after laparoscopic treatment of gallstones and common bile duct stones and to update the short-term results. Ductal stones were proven in 161 patients of 1,975 (8.1%) undergoing laparoscopic cholecystectomy. Laparoscopic transcystic CBD exploration was the method of choice. If this was unsuccessful, laparoscopic choledochotomy was performed. After treatment, all patients were enrolled in a continued, ongoing follow-up study. Laparoscopic CBD exploration was completed in 157 cases (transcystic 107, choledochotomy 50). Retained stones occurred in eight patients (5%) and major complications (cystic duct leakage, hemoperitoneum) in six (3.8%); mortality occurred in one high-risk patient (0.6%). Follow-up available in 154 patients (two unrelated deaths) for a period of up to 62 months showed the occurrence of recurrent ductal stones in five cases (3.2%) and no signs of bile stasis, suggestive of ductal stricture, on the basis of clinical and laboratory findings. This prospective, ongoing follow-up study demonstrates that laparoscopic treatment of gallstones and common bile duct stones in unselected patients is feasible and safe.

Laparoscopic choledochotomy for treatment of common bile duct stones

Laparoscopic choledochotomy for treatment of common bile duct stones

Use of a biliary stent in laparoscopic choledochotomy for removal of duct stones.

Use of a biliary stent in laparoscopic choledochotomy for removal of duct stones.

Use of a biliary stent in laparoscopic choledochotomy for removal of duct stones

Use of a biliary stent in laparoscopic choledochotomy for removal of duct stones

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones. Lessons and limits from an initial experience of 92 patients.

Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage.

Future Treatment of Common Bile Duct Stones

Management options for patients found to have common bile duct stones have expanded as a function of improved instrumentation and radiographic support. Technological advances initially lead to increased costs but eventually result in improved quality for patients. Controversy exists for patients with either soft clinical findings or stones found at the time of laparoscopic cholecystectomy. As laparoscopic common duct exploration becomes more widespread the need for perioperative ERCP will likely decrease; however, this will depend on the experience of the surgeons at a given institution. Common bile duct stones found at the time of laparoscopic cholecystectomy can be approached in a variety of different ways. The most commonly used methods are laparoscopic transcystic common bile duct exploration, laparoscopic choledochotomy with common bile duct exploration, open common bile duct exploration, laparoscopic antegrade sphincterotomy, and postoperative ERCP. In the future, the treatment goal of biliary lithiasis will be to accomplish cholecystectomy and removal of bile duct stones in a single stage. Advances in fiberoptic technology will make transcystic duct exploration more effective, but it is likely that sphincterotomy (antegrade or retrograde) will be used preferentially for the distally impacted stone.

Laparoscopic choledochotomy with primary closure. Follow-up (5-44 months) of 31 patients.

Thirty-three patients were candidates for laparoscopic choledochotomy. The indications for this operation are described. The procedure was completed 32 times (97%). We had 29 successful common bile duct (CBD) clearances, three negative explorations, and one failed clearance which needed to be converted to laparotomy. All the completed procedures ended with primary closure of the main duct. Median duration of surgery was 180 min (range 100-300), including three associated laparoscopic procedures. There were three postoperative complications (9.4%), none major. Average postoperative hospital stay was 7.1 days (range 4-14). In May-June 1995 we controlled 31 out of the 32 consecutive patients (one patient was lost to follow-up) who had a successful laparoscopic choledochotomy from October 1991 to December 1994. Median follow-up was 22 months (range 5-44). Besides clinical control, 23 patients also had ultrasound (US) controls and 24 had blood tests. Eleven had intravenous cholangiotomography. Two patients died 11 and 22 months after the operation for unrelated causes and without biliary symptoms. Two patients had umbilical hernias. One had a small residual asymptomatic stone, which was removed endoscopically. None had signs of postoperative CBD stricture. At US, CBD was </=7 mm in 15 patients, 8-10 mm in four patients, and 10-12 mm in three patients. The last group had preoperative CBD dilation, too. We could compare preoperative and postoperative CBD diameters in 22 patients: 11 had no change; in nine it decreased; and two had a slight increase (8-10 mm). We conclude that laparoscopic choledochotomy with primary closure is a very good operation: It has a high success rate and low morbidity. Mortality is nil so far. Medium-term results are very positive: We had no CBD stricture and only one case of asymptomatic residual stone, which could have been avoided. Our results suggest that intraductal biliary drainage is useless, and its specific complications are well known.

Laparoscopic transcystic cholangioscopic lithotripsy for common bile duct stones during laparoscopic cholecystectomy.

Following the recent introduction of laparoscopic cholecystectomy (LC) for cholecystolithiasis, treatment of concomitant common bile duct (CBD) stones has been evaluated by using laparoscopic choledochotomy, a transcystic approach, or by means of endoscopic sphincterotomy (ES) before or after LC. During laparoscopic cholecystectomy, we attempted lithotripsy of CBD stones using laparoscopic transcystic cholangioscopy with lithotripsy (LTCL), in 70 patients out of 950 laparoscopic cholecystectomies. Preparatory tests included laboratory values, ultrasound, and performance of endoscopic retrograde cholangiography (ERC) with placement of a nasobillary tube (without sphincterotomy). Introduction of the cholangioscope into the CBD was successful in 65 patients (92.9%) and CBD clearance was completely achieved by LTCL alone in 51 (78.5%). The overall success rate was therefore 73%. The remaining 19 cases required postoperative procedures such as extracorporeal shock-wave lithotripsy without ERC or ES (successful in all). The average hospital stay period was 9.4 days for patients in whom CBD clearance was achieved by LTCL alone. This period did not differ significantly from that of patients who underwent LC alone (8.4) days. The operation time was about 70 minutes longer for the LTCL group (total time 174 minutes on average) than for the LC group (107 minutes). We did not observe any series complications during or after LTCL (mean follow-up period: 34 months). LTCL in combination with LC allows shortening of the hospital stay and a swift return to work for patients with CBD stones. This procedure also preserves the function of the sphincter of Oddi, so that the longterm prognosis for patients is likely to be very good.

A new T-tube applier in laparoscopic surgery

In the majority of patients undergoing laparoscopic choledochotomy, it is advisable to insert a T-tube into the duct after ductal exploration, as bile sludge or fibrin deposits may obstruct the papilla and cause postoperative cholangitis. Based on our experience in open surgery, a limited transverse choledochotomy is preferred, which reduces the possibility of damaging the common bile duct blood supply. Such a technique can complicate laparoscopic T-tube positioning, however. After experimenting with the method described by Kitano et al. [Surg Endosc 7:104-105 (1993)], which was abandoned because it was difficult to carry out with the type of soft silicone rubber tubes that we normally use, two subsequent techniques were developed and are described. They were employed in 3 and 10 patients, respectively, out of 21 who underwent laparoscopic transverse choledochotomy. The most satisfying results were obtained using a system employing two sets of telescopic cannulae of different diameters. Laparoscopic T-tube introduction through a transverse choledochotomy using two telescopic cannulae was rapid and safe and allowed to precisely guide T-tube positioning inside the common duct.

Current management of common bile duct stones in northern Italy

In order to obtain a complete picture of the current management of cholecystocholedocal lithiasis in northern Italy we've conducted the present survey. In the years 1992-1993, among 7,861 cholecystectomies, 665 patients with gallbladder and common bile duct stones were treated in 49 surgical departments. Some 271 (43%) were treated by traditional methods: open surgery or endoscopic sphincterotomy followed by laparotomic cholecystectomy; 313 patients (49%) were treated by endoscopic sphincterotomy followed by laparoscopic cholecystectomy and only 38 (6%) were treated by one-stage laparoscopy, either by a transcystic approach (27) or by laparoscopic choledochotomy (11). Morbidity and mortality were not significantly different in the different groups. We conclude that open surgery and sequential minimal invasive treatment are the standard approaches to cholecystocholedochal lithiasis in this first stage of the laparoscopic era. The laparoscopic management of common bile duct stones is at present confined to surgical departments specially devoted to laparoscopic surgery.

Combination of Preoperative EST, Laparoscopic Cholecystectomy with Choledochotomy, and Postoperative Cholangioscopy in the Treatment of Common Bile Duct Stones

Abstract:A case of common duct stones, successfully managed with a combination of preoperative EST, laparoscopic choledochotomy and postoperative choledochoscopic stone extraction, is reported. A 32‐year‐old man was admitted to our hospital because of jaundice and right hypochon‐dralgia of several‐days' duration. CT, US and ERCP revealed stones in the gallbladder and common bile duct. EST was performed to remove the stones in the common bile duct prior to laparoscopic cholecystectomy. However, the patient developed pancreatitis as a complication of EST, which was successfully managed by conservative therapy. Though some stones remained in the common duct following the first trial of EST, the patient rejected a second round of EST. Laparoscopic cholecystectomy and choledochotomy were performed to remove the gallbladder and the stones remaining in the common bile duct. A T tube was placed in the incised common bile duct for management of possible retained stones. Twenty days after the surgery, successful postoperative cholangioscopy was performed, and the stones remaining in the common duct were removed. Hyperamylasemia and pancreatitis are relatively common complications of EST occurring in about 7% of cases, but only 3% of these patients experience severe pancreatitis, requiring hospitalization. Conservative therapy is always the treatment of choice. In our particular patient, pancreatitis caused by EST was successfully managed by decompression with ENBD and administration of ulinastatin. Residual stones in the CBD were completely removed by laparoscopic common bile duct exploration following EST and postoperative cholangioscopy through the T tube fistula.

Open Operations on the Bile Duct for Stones.

The management of bile duct stones attained an acceptable plateau of development in the late 1980s, with the majority of bile duct stones removed by open exploration and the difficult stone delegated to the endoscopist. This situation was disturbed by the introduction of laparoscopic cholecystectomy; it was no longer straightforward policy to explore the bile duct, and alternatives had to be considered. Open operation may now be required (1) if an unexpected stone is found during laparoscopic cholecystectomy with a small cystic duct, (2) if laparoscopic choledochotomy is undertaken and technical problems are encountered, (3) when stones in the duct cannot be removed endoscopically, (4) by preference of the surgeon on the basis of similar risk factors, (5) in the sick patient with cholangitis, and (6) after technical failure of endoscopic sphincterotomy. The technique of open operation must be meticulous and should preferably be performed with choledochoscopy either peroperatively or postoperatively. The open technique for bile duct exploration continues to have a role, and when performed expertly, its morbidity and mortality will be similar to the endoscopic and laparoscopic techniques.

Open Operations on the Bile Duct for Stones

The management of bile duct stones attained an acceptable plateau of development in the late 1980s, with the majority of bile duct stones removed by open exploration and the difficult stone delegated to the endoscopist. This situation was disturbed by the introduction of laparoscopic cholecystectomy; it was no longer straightforward policy to explore the bile duct, and alternatives had to be considered. Open operation may now be required (1) if an unexpected stone is found during laparoscopic cholecystectomy with a small cystic duct, (2) if laparoscopic choledochotomy is undertaken and technical problems are encountered, (3) when stones in the duct cannot be removed endoscopically, (4) by preference of the surgeon on the basis of similar risk factors, (5) in the sick patient with cholangitis, and (6) after technical failure of endoscopic sphincterotomy. The technique of open operation must be meticulous and should preferably be performed with choledochoscopy either peroperatively or postoperatively. The open technique for bile duct exploration continues to have a role, and when performed expertly, its morbidity and mortality will be similar to the endoscopic and laparoscopic techniques.

Laparoscopic choledochoscopy with a small-caliber endoscope

Incidental choledocholithiasis has been reported in 4-5% of cases during routine cholangiography. Many surgeons have resisted laparoscopic common bile duct exploration as a time-consuming and technically frustrating procedure, preferring to send the patient for postoperative ERCP. The purpose of this study was to objectively assess the safety, efficacy, and facility of transcystic duct choledochoscopy using a small-caliber choledochoscope with facilitated insertion technique. Twenty-five consecutive patients scheduled for laparoscopic cholecystectomy (LC) were studied prospectively. Choledochoscopy was carried out with a simplified introducer system using a 6.9-French choledochoscope. An arbitrary limit of 10 min was established for gaining access to the common bile duct (CBD). Incidental CBD stones were found in two of the 25 procedures (8%) and were cleared laparoscopically. The CBD was successfully entered in 21 of 25 attempts (84%). The average time for the entire procedure was 8.7 min. There were no procedure-related complications. Clinical application of this procedure was reviewed in a personal series of 742 LCs. Transcystic laparoscopic common bile duct exploration (LCDE) was successful in clearing stones from the CBD 75% of the time and the addition of laparoscopic choledochotomy brought the success of LCDE to 81%. Excluding patients where transcystic LCDE was not attempted, the overall success rate was 91%.

Controversies in the management of common duct calculi

Patients less than 65 years of age who have symptomatic cholelithiasis should undergo laparoscopic cholecystectomy with interoperative cholangiography. When calculi are encountered, the transcystic duct technique of bile duct exploration is applicable in 80% to 90% of patients. When the common bile duct calculus is larger than 1 cm, the patient is a candidate for laparoscopic choledochotomy. Based on present data, when the patient is less than 65 years of age, open common bile duct exploration is safer than endoscopic sphincterotomy, although in the future we may have long-term follow-up studies on endoscopic sphincterotomy in this younger age group. Patients more than 65 years of age undergoing elective laparoscopic cholecystectomy are candidates for preoperative endoscopic sphincterotomy if they have an ultrasound diagnosis of choledocholithiasis or a high likelihood of harboring common bile duct calculi. They are also candidates for laparoscopic techniques of common bile duct exploration and intraoperative or postoperative endoscopic sphincterotomy. Open surgery and biliary bypass should be considered in complex situations that are not suitable for endoscopic sphincterotomy. Finally, local expertise and the complexity of the individual case influence the treatment of patients with choledocholithiasis.