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

Abstract

INTRODUCTION The aim of this study was the assessment of patient outcome, peri-operative complications, length of stay and duration of operation after laparoscopic primary closure of the common bile duct (CBD) compared with choledochotomy with T-tube drainage and trans-cystic exploration. PATIENTS AND METHODS Analysis of prospectively collected data on 71 explorations of the common bile duct between July 2001 and March 2006. RESULTS A total of 71 patients had exploration of the CBD. Within this group, 12 were referred after failed endoscopic retrograde cholangiopancreatography (ERCP). The methods of exploration included trans-cystic (9 cases), choledochotomy with Ttube (12), and choledochotomy with primary closure (50). CBD stones were found in 66 patients. In the remaining cases, we found a stricture in 1, debris in 2, and dilatation of the CBD without a stone in 2. There were 5 conversions to open technique and 3 patients required postoperative ERCP (1 with permanent stenting). Peri-operative complications included T-tube (3), primary closure group (9), and trans-cystic (0). There was no statistical significant difference (Chi-square test, P = 0.296) between the groups. There was a trend towards a shorter length of stay in the primary closure group as compared with the trans-cystic and T-tube groups of 4.16, 4.44, and 6.33 days, respectively. However, it did not reach statistical significance (one-way analysis of variance with Boneferroni correction, mean difference between groups 1.89, 0.28, 2,17, statistical significance at P < 0.05). The shortest operating time was in the primary closure group (95.92 min) which was statistically significant (P < 0.001). We did not use a biliary drain in the last 48 patients. CONCLUSIONS Primary laparoscopic closure of the CBD is safe and results in a reduction in operating time. Choledochoscopy ensures clearance of the CBD and eliminates the need for T-tube.

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

“…tic duct anatomy (tortuous, < 3 mm in diameter), proximal (hepatic duct) stones, strictures and large (> 6 mm) or numerous stones (> 5) [43][44][45] . 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] .…”

“…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] .…”

Primary Closure Following Laparoscopic Common Bile Duct Reexploration for the Patients Who Underwent Prior Biliary Operation

“…During the conservative treatment process, if the volume of bile in the drain had increased and choledochotomy site patients started to develop signs of extensive biliary peritonitis, they would undergo another laparoscopic operation. Additional sutures would be needed if there is a leak from the choledochotomy site [17].…”

The Role of Choledochoscopy in Hepatopancreatobiliary Diseases

“…Additionally, electrohidrolic or laser lithotripsy can be performed by this technique [3,18,[21][22][23][24][25][26][27]. On the other hand, some other major application areas of choledochoscopy are biopsy or cytology for the diagnosis of biliary tract malignencies, intrabiliary rupture of hydatid cysts, balloon dilatation of the biliary tract, electrocoagulation, or stent application for biliary malignencies [3,6,7,11,12,14,16,17,26,[28][29][30][31][32][33], similar to our study.…”