Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis

Abstract

Six hundred twenty-two laparoscopic cholecystectomies were performed at St. Vincent Hospital over a 14-month period. We reviewed the records of 366 of these patients who were referred to the authors. Thirty-six patients had suspected choledocholithiasis. The primary author (M.E.A.) performed 38 endoscopic retrograde cholangiopancreatography (ERCPs) on these patients for diagnosis and management. Seventeen of the 36 patients had common bile duct stones; 19 patients had negative studies. Of the 17 patients with choledocholithiasis, 15 had successful cannulation of the common bile duct, and, of these, 10 underwent laparoscopic cholecystectomy plus endoscopic sphincterotomy and extraction of the common duct stone(s). In one high-risk elderly patient, we extracted the stone from the common duct and left the gallbladder in situ. Two patients failed endoscopic cannulation and underwent open cholecystectomy with common bile duct exploration. Four additional patients, cannulated successfully, had unsuccessful endoscopic stone removal because the stones were too large or were impacted. Two of these patients underwent open cholecystectomy and common duct exploration. The two other patients underwent laparoscopic cholecystectomy and choledochoscopy through the cystic duct with the flexible choledochoscope. An electrohydraulic lithotripsy probe was then inserted through the choledochoscope to fragment the stones, and stone fragments were allowed to pass through the previously created sphincterotomy. We believe our data, supported by data in the literature, show that these alternative methods for treating choledocholithiasis are safe and effective and should be considered primary modalities for treating this condition now that laparoscopic cholecystectomy is the treatment of choice for cholelithiasis.

Laparoscopic management of choledocholithiasis

“…Its advantages are associated with treatment in a single procedure, low morbidity and mortality rates among selected patients, short hospital stay, and rapid return to normal activities. As previously demonstrated, the transcystic approach is technically feasible in most cases, and is associated with a high rate of biliary clearance in selected patients [2,5,10,16,17]. Despite the preference of some authors [16,17] for the initial use of a choledochoscope, this procedure requires cystic dilation in some cases and has limitations in retrieving larger stones.…”

“…Choledocholithiasis, however, has been managed by pre-, intra-, or postoperative ERCP. Some authors [1,2] have demonstrated the effectiveness of the pre-and postoperative endoscopic approach with high success rates, low morbidity and mortality, and a short hospital stay. However, some disadvantages have been observed, such as the need for more than one procedure, success rates of about 90%, unnecessary preoperative ERCP due to the low predictability rates of laboratory tests and ultrasonography, and the probability of failure in postoperative procedures.…”

“…Laparoscopic cholecystectomy, with the advantages of technical feasibility for the majority of patients, short hospital stay, fast return to previous activities, and good aesthetic results, is becoming the alternative of choice for the management of symptomatic cholelithiasis. Endoscopic management of common bile duct stones during the preoperative period is associated with high success rates and low morbidity and mortality rates [1,2] and was the alternative preferred by the authors during the early stage of their experience with laparoscopic cholecystectomy. However, due to the need for a second procedure, the possibility of therapeutic failure, and the morbidity and mortality related to endoscopic papillotomy, we changed our management scheme of choledocholithiasis to laparoscopic common bile duct exploration, which has recently been described [5,10,16,17].…”

A pig model for advanced laparoscopic biliary procedures

“…Although perioperative endoscopic retrograde cholangiopancreatography (ERCP) may be a preferred method for handling CBD stones in the laparoscopic era [4], laparoscopic CBD exploration is also being promoted [1,5,6]. We have developed a simple pig model which has assisted us in practicing advanced laparoscopic biliary procedures in the animal laboratory.…”

Common duct stones: removal before or during laparoscopic cholecystectomy?

“…We disagree with a few points in Dr. Arregui's recent article [1]. We believe that preoperative ERCP/ES should be restricted to elderly patients or patients with cholangitis.…”