Laparoscopic Choledochoscopy: An Effective Approach to the Common Duct

Abstract

With increasing acceptance of routine cholangiography during laparoscopic cholecystectomy (for confirmation of anatomy) there has been increased identification of common duct calculi. A technique of laparoscopic transcystic common duct stone extraction is described and early clinical results are presented. Successful stone extraction was accomplished in 39 out of 41 consecutive attempts by one surgical team. Two cases required choledochotomy. There were four complications including hyperamylasemia (2), minor wound infection (1), and incidental pneumothorax (1). Recommendations regarding safety and indications are presented. Initial evaluation suggests laparoscopic transcystic stone extraction is safe and effective.

Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis

“…The use of a guidewire, allowing an anterograde cannulation of the papilla, avoids the risk of inadvertent cannulation of the pancreatic duct, with possible related complications. Laparoscopic transcystic duct exploration [3,4,11] or laparoscopic choledochotomy [9,10] and duct exploration are alternative methods of duct clearance. Transcystic duct exploration should always be attempted first, but it may not always result in successful narrowing of the cystic duct lumen.…”

Laparoscopic common bile duct exploration

“…ERC ± S has been shown to be successful in clearing the CBD in >90% of cases [19][20][21][22]. Similarly, LCBDE is successful in clearing the duct in >90% of cases as well [10,11,[23][24][25]. The choice of clearance method should be based on the local availability of expert endoscopists capable of a high degree of success with ERC ± S, the availability of laparoscopic and choledochoscopic equipment, the surgeon's own expertise in laparoscopic surgery, and the general condition of the patient [5,7,19,25,26].…”

“…These include administration of glucagon, dilatation of the distal CBD, balloon catheter manipulation, basket manipulation-with or without fluoroscopic guidance, and choledochoscopic manipulations [9][10][11][12][13][14][15][16][17][18]. All of these techniques presuppose that IOC has been performed, whether or not preoperative ductal evaluation (chemical, radiographic, or endoscopic) has been used to evaluate or treat the CBD pathology prior to that time.…”

“…Laparoscopic choledocholithotomy can be accomplished with a variety of techniques [9][10][11][12][13][14][15][16][17][18]. These are usually applied in the order of ascending invasiveness as determined by the specific findings of each case.…”

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

“…However, the diagnosis of choledocholithiasis based on predictable clinical and laboratory criteria has had a high failure rate. Approximately 0.9-8.8% of patients have presented, in their intraoperative cholangiography, images suggesting choledocholithiasis [13,20].Currently, choledocholithiasis can be treated by a number of alternatives such as endoscopic choledocholitotomy, intracorporeal and extracorporeal lithotripsy, interventional radiology, chemical dissolution, and open and laparoscopic surgery.There is a growing interest among laparoscopic surgeons in treatment of biliary tract diseases via a combination of techniques and endoscopic instrumentation (with high success rates) using the cystic duct, choledochotomy, or both [6,9,10,16,18,19] for entry.Usually a T-tube is placed after choledochotomy for the external biliary drainage, which increases the postoperative discomfort and morbidity. Our goal was to demonstrate the technical feasibility and clinical results of the routine use of a modified 10-Fr biliary stent to drain the common bile duct after laparoscopic choledochotomy.…”