Laparoscopic management of choledocholithiasis

Abstract

The authors report on a group of 114 patients with common bile duct (CBD) stones who were treated by laparoscopic surgery. Management through the cystic duct was considered the first option. Choledochotomy was used for those patients in which the cystic approach was not possible or was unsuccessful. Transcystic lithotripsy was considered for patients with CBD stones in disproportion with the size of the cystic duct. Laparoscopic antegrade sphincterotomy was indicated as a drainage procedure. The transcystic approach was used in 89.5% of the patients; choledochotomy was used in 6.2%; and both ways were used in 4.3%. Different procedures were used, including mechanical and electrohydraulic lithotripsy, choledochotomy with T-tube or endoprostheses drainage, laparoscopic sphincterotomy, end-to-end common bile duct anastomosis, and choledochoduodenum anastomosis. One of the patients was in the 21st week of pregnancy. The laparoscopic approach to choledocholithiasis was successfully performed in 94.8% of the patients. Mean hospital stay was 1.7 days. There was a 6.2% incidence of complications and the mortality rate was 0.9%. In 84.3% of the patients, the transcystic approach was used successfully, with a complication rate of 4.9% and a mean hospital stay of 1.6 days. Three patients were converted to open surgery early in this series. Thus far, one patients has presented residual CBD stones. The results obtained suggest that laparoscopic common bile duct exploration is a technically feasible procedure, with low complication and mortality rates, although it requires adequate selection of patients and a variety of techniques and types of equipment.

Laparoscopic treatment of choledocholithiasis using modified biliary stents

“…The idea of the antegrade biliary stent was proposed by DePaula et al [4], Rhodes et al [14], Lange et al [9], and Gersin and Fanelli [7] as a way to avoid the need for a T-tube. DePaula et al [5], especially, suggested T-tube use as a routine procedure.…”

Minimally invasive treatment of cholecysto-choledocal lithiasis: The point of view of the surgical endoscopist

“…Following laparoscopic choledochotomy, closure over a T-tube may be required if the common bile duct is inflamed [46][47][48] . Extraction of ductal stones via an endoscopic biliary sphincterotomy may be difficult or inappropriate for a variety of reasons, including size, shape and number of stones, intrahepatic location, stone impaction, Billroth Ⅱ gastrectomy or Roux-en-y anatomy, recurrent bile duct stones after prior open exploration of the CBD and biliodigestive anastomosis, periampullary diverticula, and Mirizzi syndrome [8,49] . It is important that adequate biliary drainage is ensured in patients with CBD stones that have not been extracted by standard or advanced (such as lithotripsy) endoscopic techniques, eventually by a temporary biliary stent.…”

“…ERCP training program is mandatory to achieve selective cannulation rates in excess of 80%. It is important that once formal training is completed endoscopists perform an adequate number of biliary sphincterotomies (40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50) per year to maintain their performance. It is recommended that all endoscopists performing ERCP should be able to supplement standard stone extraction techniques with advanced techniques (mechanical lithotripsy, electro-hydraulic lithotripsy and laser lithotripsy) when required [52][53][54][55][56][57] .…”

Minimally invasive (laparoscopic) surgery

“…This technique compared favorably to the open CBD technique. Depaula et al[59] reported on 114 patients with CBD stones treated by laparoscopic surgery. Transcystic stone removal and/or choledochotomy were the techniques used.…”