Laparoscopic Treatment of Gallbladder and Common Bile Duct Stones: A Prospective Study

Abstract

The aim of this study was to investigate prospectively the feasibility, success rate, safety, and short-term results of single-stage laparoscopic treatment of gallstones and ductal stones in 100 consecutive, unselected patients. Common bile duct (CBD) stones were diagnoses at routine intraoperative cholangiography and choledochoscopy in 100 of 950 patients with gallstones undergoing laparoscopic cholecystectomy (LC). Unsuspected CBD stones were present in 39 patients (4.1% of 950; 39% of 100); 26 patients were referred for surgery after failed endoscopic sphinctertomy (ES) performed elsewhere. Transcystic duct CBD exploration (TC-CBDE) was the procedure of choice. When it was not feasible, choledochotomy and direct CBD exploration (D-CBDE) was performed. Use of biliary drainage was liberal. A completion cholangiogram was obtained for all patients. Laparoscopic treatment of CBD stones was successful in 96 patients: after TC-CBDE in 63 and after D-CBDE in 33. Four operations were converted to open surgery (4%). Retained stones, observed in five patients, were treated by ES in two cases and by percutaneous endoscopic/fluoroscopic lithotripsy in three. Minor morbidity included biloma (n = 2), port site infection (n = 2), and subumbilical hematoma (n = 1). Major morbidity was bile leakage from the cystic duct stump in two cases due to clips or transcystic duct drainage displacement, respectively. One elderly, high risk patient died after being referred for several failed attempts of endoscopic clearance; she died from cardiogenic shock 3 days after successful laparoscopic treatment. Laparoscopic CBD exploration is feasible and safe in most patients, with short-term results that compare favorably with the results of sequential ES/LC reported in the literature.

Trend towards Primary Closure Following Laparoscopic Exploration of the Common Bile Duct

“…17 Factors required to achieve a high success rate in LECBD include adequate training, standardisation of surgical technique and accurate selection of the most correct position of the mid-clavicular trochar. 18 With the continuous refinement of our operating technique, we managed to keep our conversion rate of 7% within a range reported in other series. 4,7,11,17,19 We achieved laparoscopic CBD clearance in 62 (88.7%) patients, 5 conversions and 3 subsequent endoscopic retrievals.…”

Laparoscopic cholecystectomy and common bile duct exploration are safe for older patients

“…This condition may develop after any instrumental maneuver on the papilla such as transpapillary passage of the Dormia basket or lithotripsy of impacted stones, which may be followed by postoperative edema of the papilla. The biliary drainage is secured in place with a 4/0 monofilament absorbable transfixing suture on a straight needle (PDS II, Z620; Johnson & Johnson International, e/o European Logistics Centre, B-I130, Brussels, Belgium) according to a personal technique [7,8]. If the papilla has not been disturbed during the exploration maneuvers, no biliary drainage is initiated.…”

Evidence-based clinical practice guidelines for cholelithiasis 2016

“…Published reports on the laparoscopic treatment of choledocholithiasis include both cohort studies and individual series [167][168][169][170][171][172][173][174][175][176]. Switching to open surgery occurred in 1.4-13% of procedures [167][168][169][170][171][172][173][174][175][176], and transcystic stone removal was performed more frequently than choledochotomy, with the former being performed in 60-70% of cases [167][168][169][170][171][172][173][174][175][176]. All of these reports found that laparoscopic one-stage removal of common bile duct stones is noninferior to two-stage removal using a peroral endoscope and that laparoscopic surgery can be performed in most cases of choledocholithiasis.…”