Laparoscopic Antegrade Sphincterotomy

Abstract

The authors describe the technique and results of laparoscopic antegrade sphincterotomy. The procedure was performed in 42 selected cases of choledocholithiasis. The indications for attempting laparoscopic antegrade sphincterotomy included impacted stones in the papilla, multiple common bile duct stones, one or more common hepatic or intrahepatic stones, dilated common bile duct requiring a drainage procedure, suspicion of papillary stenosis, whenever numerous fragments are found after lithotripsy, and as an adjunct procedure when the surgeon cannot completely remove all the stones in the bile ducts. No major complications or mortality was observed. One patient had a selflimited drop in the hematocrit and four patients presented with transitory mild hyperamylasemia that returned to normal levels in 72 hours. Laparoscopic antegrade sphincterotomy added an average of 17 minutes to the laparoscopic operation. The mean postoperative stay was 1.4 days. The results of this study conclude that laparoscopic antegrade sphincterotomy is an option of great therapeutic value for selected cases when drainage of the biliary tract concomitant to the treatment of choledocholithiasis is necessary. Copyright© 1997 by W B. Saunders CompanyGurrently, laparoscopic cholecystectomy is the procedure of choice in the treatment of patients with symptomatic cholelithiasis.' For those 10 to 15 patients with suspected or proven choledocholithiasis in association, the best treatment remains a challenge for the laparoscopic surgeon.2The controversy in choosing the appropriate approach for patients with cholelithiasis and common bile duct stones (CBD) is related to the clinical presentation and associated disease processes, presence of complications, difficulty in obtaining a precise preoperative diagnosis, and availability of equipment, as well as expertise of the surgical team. Many treatment modalities have been proposed, including conversion to open surgery, pre or postoperative endoscopic retrograde cholangiopancreatgraph (ERCP), intraoperative endoscopy with endoscopic sphincterotomy (ES), and laparoscopic common bile duct exploration. Current evaluation of the results of ERCP and ES for CBD stones demonstrates a 90% to 95% success rate and 5% to 10% incidence of major complications. Mortality is less than 1%. The development of late complications such as papillary stenosis, recurrent CBD stones, and cholangitis ranges from 5% to 10%.3-6 Intraoperative ERCP and sphincterotomy during laparoscopic cholecystectomy has the advantage of treating both gallbladder and CBD stones in a single procedure, technical feasibility, and probably a lower incidence of pancreati tiS.7 The disadvantages include the need of special equipment in the operative room, presence of an experienced endoscopist, the supine position of the patient, and abdominal distension mandated by the laparoscopic procedure.Laparoscopic common bile duct exploration, both transcystic and through a choledochotomy, is currently associated with a high success rate and low morbidit...

Laparoscopic common bile duct exploration

“…[53] who treated ten patients with transcystic saline flushing after dilation of the papilla. Results of unique techniques have been reported by other authors [61,62,63]. Ido et al [61] reported the results of laparoscopic transcystic cholangioscopy with lithotripsy.…”

“…In their experience, this approach was succesful in 78.5% of cases when used alone and in 92.9% of cases when other transcystic clearing methods were used. De Paula et al [62] and Curet et al [63] described the results of laparoscopic antegrade sphincterotomy. They reported no mortality, no major complications and no recurrence of papillary stenosis in a follow-up of 1-18 months [62] and 5 months [63]), respectively.…”

“…In the former, a sphincterotome is inserted through the cystic duct or through a choledochotomy and advanced through the papilla. Under direct vision from an orally placed choledochoscope, the sphincterotomy is then performed at the 11-12 o'clock position of the papilla [34]. In the retrograde technique, the sphincterotomy is performed, introducing and maneuvering the sphincterotome through the duodenoscope.…”

Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) to remove common bile duct stones during routine laparoscopic cholecystectomy does not prolong hospitalization: a 2-year experience

“…In this article, we report our experience during the first 2 years of combining LC with IO-ERCP, using a modified version of the techniques previously described in the literature [7,10,14].…”

Management of Bile Duct Stones in the Era of Laparoscopic Cholecystectomy

“…The laparoscopist may then employ standard stone extraction techniques as well as flexible choledochoscopy and lithotripsy to clear the duct. Ampullary balloon dilation [71] and antegrade sphincterotomy under endoscopic observation [72] have both been performed with transcystic LCBDE to maximize duct clearance. A few surgeons have also successfully performed laparoscopic choledochotomy, a highly challenging procedure which enhances access to the proximal biliary tree and is usually followed by T-tube placement.…”