Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures.

OBJECTIVE: To establish a simple, reproducible, and safe technique of laparoscopic common bile duct exploration (CBDE) with high clearance rates and low morbidity and mortality rates. SUMMARY BACKGROUND DATA: For most general surgeons, laparoscopic CBDE appears an unduly complex and demanding procedure. Since the introduction of laparoscopic cholecystectomy, many surgeons use endoscopic cholangiography (ERC) and endoscopic sphincterotomy as their only option in treating bile duct stones. ERC is more specific if used after surgery, but it carries an appreciable morbidity rate and has the disadvantage of requiring a second procedure to deal with bile duct stones. To this end, various methods of laparoscopic CBDE have been developed. METHODS: Between August 1991 and February 1997, 300 consecutive unselected patients underwent laparoscopic CBDE. RESULTS: Of 300 laparoscopic CBDE procedures, 173 (58%) were managed using a transcystic approach and 127 (42%) with choledochotomy. Successful laparoscopic stone clearance was achieved in 271 (90%). Of the 29 (10%) patients not cleared laparoscopically, 10 had an elective postsurgical ERC, 12 were converted to an open procedure early in the series, and 7 had unexpected retained stones. There was one death (mortality rate 0.3%) and major morbidity occurred in 22 patients (7%). The last 100 procedures were performed from July 1995 to February 1997, and stone clearance was unsuccessful in only two patients. CONCLUSIONS: Laparoscopic transcystic basket extraction of common duct stones under fluoroscopic guidance is a relatively quick, successful, and safe technique. Choledochotomy, when required, is associated with a higher morbidity rate, particularly with T-tube insertion, and the authors advocate primary bile duct closure with or without insertion of a biliary stent as a more satisfactory technique for both surgeon and patient. Most patients with gallbladder and common duct calculi should expect a curative one-stage laparoscopic procedure without the need for external biliary drainage or ERC.     

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones

Background: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. Methods: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. Results: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. Conclusions: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage. Received: 7 May 1996/Accepted: 19 November 1996     

Laparoscopic choledochotomy for bile duct stones

In the era of laparoscopic surgery, treatment strategies for common bile duct stones remain controversial. Laparoscopic choledochotomy is usually indicated only when transcystic duct exploration is not feasible. However, laparoscopic choledochotomy provides complete access to the ductal system and has a higher clearance rate than the transcystic approach. In addition, primary closure of the choledochotomy with a running suture and absorbable clips facilitates the procedure. Therefore, to avoid postoperative biliary stenosis, all patients with bile duct stones can be indicated for choledochotomy, except for those with nondilated common bile duct. Placement of a C-tube also provides access for the clearance of possible retained stones by endoscopic sphincterotomy as a backup procedure. C-tube placement, in contrast to T-tube insertion, is advantageous in terms of a relatively short hospital stay. In conclusion, laparoscopic choledochotomy with C-tube drainage is recommended as the treatment of choice for patients with common bile duct stones. Received: February 27, 2001 / Accepted: March 19, 2001     

腹腔镜下经胆囊管造影网篮胆总管结石取出术

目的探讨腹腔镜胆囊切除时经胆囊管取出胆总管结石的可行性. 方法回顾性分析2003年1月～2004年7月经胆囊管胆道造影18例的临床资料.腹腔镜下切除胆囊之前切开胆囊管,插入造影管行胆道造影,发现胆总管结石后,经胆囊管插入金属网篮,取出胆总管结石. 结果经胆囊管行胆总管造影18例,发现胆总管结石11例,其中2例因结石明显大于胆囊管直径,2例因导管无法经胆囊管进入胆总管,1例因结石嵌顿于壶腹部套篮无法套取结石而放弃腹腔镜下经胆囊管胆总管结石取出,余6例成功完成腹腔镜下经胆囊管胆总管结石取出术.6例随访6～18个月,B超检查未发现胆总管结石残留,无胆总管狭窄或扩张. 结论腹腔镜下经胆囊管胆总管结石取出术可作为部分继发性胆总管结石的术中诊断和治疗手段.     

Treatment of Common Bile Duct Stones Discovered during Cholecystectomy

Background Several techniques of laparoscopic bile duct exploration and intraoperative endoscopic sphincterotomy (ES) have been developed to treat patients with common bile duct (CBD) stones in one session and avoid the complications of ES. With all these options available, very few randomized controlled trials (RCTs) have been undertaken. This review analyzes those studies. Methods We searched PubMed. Four RCTs and a Cochran Database Systematic Review were found. Results Two RCTs compared preoperative ES and laparoscopic CBD exploration (E) for known CBD stones. Laparoscopic CBDE had shorter length of hospitalization. Two RCTs compared immediate and delayed treatment and found that length of stay was less with laparoscopic CBDE, but clearance rates and morbidity/mortality were similar. Conclusions Studies suggest that CBD stones discovered at the time of cholecystectomy are best treated during the same operation. The transcystic approach is safest if applicable. Individual surgeons must be aware of their own capabilities and those of the available endoscopists and perform the safest technique. Presented at the Postgraduate Course of the 48th Annual Meeting of the Society for Surgery of the Alimentary Tract, May 20, 2007, Washington D.C., USA.     

Laparoscopic endobiliary stenting as an adjunct to common bile duct exploration

Background: The management of common bile duct stones (CBDS) in the era of operative laparoscopy is evolving. Several minimally invasive techniques to remove CBDS have been described, including preoperative endoscopic retrograde cholangiopancreatography (ERCP), postoperative ERCP, lithotripsy, laparoscopic transcystic common bile duct exploration, and laparoscopic choledochotomy with common bile duct exploration (CBDE). Because of the risks and limitations of these procedures, we utilize laparoscopically placed endobiliary stents as an adjunct to CBDE. Methods: Sixteen patients underwent laparoscopic common bile duct exploration (LCBDE) by either choledochotomy or the transcystic technique with placement of endobiliary stents. These patients were identified during laparoscopic cholecystectomy as having occult choledocholithiasis, using routine dynamic intraoperative cholangiography. Results: CBDS were successfully removed in all patients as demonstrated by completion cholangiography and intraoperative choledochoscopy. Eighty percent of patients were discharged the following day; the first three patients in this series were observed for 48 h prior to discharge. No patient required T-tube placement and closed suction drains were removed the morning after surgery. Stents were removed endoscopically at 1 month. Six- to 30-month follow-up demonstrates no complications to date. Conclusions: Laparoscopic endobiliary stenting reduces operative morbidity, eliminates the complications of T-tubes, and allows patients to return to unrestricted activity quickly. We recommend laparoscopically placed endobiliary stents in patients undergoing LCBDE.     

Laparoscopic management of common bile duct stones

Laparoscopic common bile duct exploration (CBDE) was the subject of a multi-institutional study on 226 patients from 19 major hospital centers. Female patients predominated (2.3:1); the average age was 54; 75% of cases were chronic, and the remainder were acute. Although 97% had preoperative ultrasonograms, only 12% showed a stone in the dilated common bile duct. The alkaline phosphatase was elevated in 41% and the serum bilirubin in 28% of cases. Preoperative endoscopic retrograde cholangiography with sphincterotomy (ERC-ES) was performed in 8.5%; there was a successful stone extraction in less than half the cases. Cholangiography was performed in 99.5%, and in 94% of those cases, stones were found.In 83% of cases, stones were removed through the transcystic approach, and in 17% removal was throughout the CBD. In the majority of cases, the choledochoscope and wire basket (34%), irrigation (33%), or a combination of both was employed. In the transcystic group, 5% were converted to open procedures due to technical difficulty, as contrasted with the trans-CBD route, where the conversion rate was 19%. There were two ductal injuries. Minor complications occurred in 5.7% within 24 h; there was one death (0.4%). Within 30 days, the morbidity rate was 7% and there were no deaths. Retained stones were discovered in 2.6% of cases.Laparoscopic CBDE is a feasible approach for CBD stones which permits a definitive procedure in one stage, without pre- or postoperative ES. It is a skill which should be mastered by the biliary surgeon. Further improvement in instrumentation and technique should make the laparoscopic approach not only comparable but preferable to the standard open choledocholithotomy.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA 18–19, April 1994     

Current management of concomitant cholelithiasis and common bile duct stones

The management policy of concomitant cholelithiasis and choledocholithiasis is based on a one-or two-stage procedure. It basically includes either laparoscopic cholecystectomy(LC) with laparoscopic common bile duct(CBD) exploration(LCBDE) in the same operation or LC with preoperative, postoperative and even intraoperative endoscopic retrograde cholangiopancreatography-endoscopic sphincterotomy(ERCP-ES) for stone clearance. The most frequently used worldwide option is preoperative ERCP-ES and sto...     

Choledochoscopy as a diagnostic and therapeutic tool for common bile duct stones

Aim-Background

The aim is to present the results of a retrospective study comparing a) choledochoscopy in open and laparoscopic Common Bile Duct Exploration (CBDE) regarding the clearance of Common Bile Duct (CBD) from stones, b) open CBDE with and without choledochoscopy, and c) transcystic vs. transductal laparoscopic choledochoscopy.

Patients-Methods

Data were extracted from the medical records of 251 patients who had undergone open or laparoscopic Common Bile Duct Exploration. We excluded all those undergoing successful ERCP and sphincterotomy. The patients were separated into the following groups Group A: 127 patients who underwent Open CBDE; subgroup A1 comprised 52 patients who underwent Open CBDE with flexible choledochoscopy and intraoperative cholangiography (open CBDE+FCS+IOC), and Subgroup A2 included 75 patients who underwent Open CBDE with cholangiography (open CBDE+IOC). Group B: 124 patients who underwent Laparoscopic CBDE; subgroup B1 included 15 patients undergoing transcystic choledochoscopy, and subgroup B2 comprised 109 patients who underwent transductal choledochoscopy.

Results

The stone clearance rate in group A1 (open CBDE +FCS+IOC) was 98%, and in group A2 (open CBDE +IOC) it was 93%. However, the difference in the success rate between the choledochoscopic and “blind” technique was of no statistical significance (p=0.235). Similarly, no statistical significance was found between the success rates of open (98%) vs. laparoscopic (94%) choledochoscopy (p=0.869), or transcystic (Group B1) vs. transductal (GroupB2) laparoscopic choledochoscopy (87% vs. 95% respectively) (p=0.207), although greater success was noted in favour of transductal choledochoscopy. The conversion rate of transductal laparoscopic CBDE was 8%, and the main reason for conversion was stone impaction.

Conclusion

No statistical difference is noted in stone clearance rate between flexible choledochoscopy (FCS) and intraoperative cholangiography. However, intraoperative cholangiography has better outcomes regarding stone clearance when it is assisted by choledochoscopy. A search of the literature found no available data comparing the success rate of open vs. laparoscopic choledochoscopy. Our study demonstrated that the difference in the stone clearance rate between the two approaches was not statistically significant. Laparoscopic transcystic CBDE is less invasive and is associated with a lower complication rate, but it has higher failure rates compared to the transductal approach, although the difference is of no statistical significance.     

A balanced approach to choledocholithiasis

Background: We set out to review and evaluate the results of an algorithm for managing choledocholithiasis in patients undergoing laparoscopic cholecystectomy. Methods: We performed retrospective review of patients with choledocholithiasis at the time of laparoscopic cholecystectomy (LC) between March 1993 and August 1999. All patients were operated on under the direction of one surgeon (M.E.A), following a consistent algorithm that relies primarily on laparoscopic transcystic common bile duct exploration (TCCBDE) but uses laparoscopic choledochotomy (LCD) when the duct and stones are large or if the ductal anatomy is suboptimal for TCCBDE. Intraoperative endoscopic retrograde sphincterotomy (ERS) is done if sphincterotomy is required to facilitate common bile duct exploration (CBDE). Postoperative endoscopic retrograde cholangiopancreatography (ERCP) is utilized when this fails. Preoperative ERCP is used only for high-risk patients. Results: A total of 728 LC were performed, and there were 60 instances (8.2%) of choledocholithiasis. Primary procedures consisted of 47 TCCBDE; 37 of them required no other treatment. In five cases, the stones were flushed with no exploration. Intraoperative ERS was performed three times as the only form of duct exploration. LCD was utilized twice; one case also required intraoperative ERS, and the other had a postoperative ERCP for stent removal. One patient with small stones was observed, with no sequelae. Preoperative ERCP was done twice as the primary procedure. Of the 10 cases that were not completely cleared by TCCBDE, three had a postoperative ERCP and seven had an intraoperative ERS, one of which required a postoperative ERCP. There were three complications (6%) related to CBDE, with no long-term sequelae. There were four postoperative complications (6.7%) and no deaths. The mean number of procedures per patient was 1.12. The average postoperative hospital stay was 1.8 days (range, 0-14). Conclusions: Choledocholithiasis can be managed safely by laparoscopic techniques, augmenting with ERCP as necessary. This protocol minimizes the number of procedures and decreases the hospital stay.     

The utility of laparoscopic common bile duct exploration in the treatment of choledocholithiasis

Laparoscopic common bile duct exploration (CBDE) was performed in 24 patients over a 23-month period. Fourteen of these patients were suspected preoperatively of harboring common bile duct (CBD) calculi. Of these, endoscopic sphincterotomy was unsuccessful in eight. Laparoscopic CBDE was performed either transcystically or via a choledochotomy. In all cases, completion cholangiography demonstrated that the CBD was free of stones. All patients were sent home with drains placed in their extrahepatic biliary system. Mean hospital stay was 2.7 days. There was no mortality. The overall morbidity rate was 29.1%. It included one trocar site infection (4.1%), four cases of mild postoperative amylasemia (16.6%), and two cases of retained stones (8.3%) seen in two patients on follow-up tube cholangiography that were successfully extracted percutaneously. The authors feel that laparoscopic CBDE is a safe and effective method of CBD stone removal that offers an alternative to preoperative ERCP and sphincterotomy.     

Follow-up of 161 unselected consecutive patients treated laparoscopically for common bile duct stones

Background: Aim was to study the incidence of recurrent ductal stones and of biliary strictures at follow-up after laparoscopic treatment of gallstones and common bile duct stones and to update the short-term results. Methods: Ductal stones were proven in 161 patients of 1,975 (8.1%) undergoing laparoscopic cholecystectomy. Laparoscopic transcystic CBD exploration was the method of choice. If this was unsuccessful, laparoscopic choledochotomy was performed. After treatment, all patients were enrolled in a continued, ongoing follow-up study. Results: Laparoscopic CBD exploration was completed in 157 cases (transcystic 107, choledochotomy 50). Retained stones occurred in eight patients (5%) and major complications (cystic duct leakage, hemoperitoneum) in six (3.8%); mortality occurred in one high-risk patient (0.6%). Follow-up available in 154 patients (two unrelated deaths) for a period of up to 62 months showed the occurrence of recurrent ductal stones in five cases (3.2%) and no signs of bile stasis, suggestive of ductal stricture, on the basis of clinical and laboratory findings. Conclusions: This prospective, ongoing follow-up study demonstrates that laparoscopic treatment of gallstones and common bile duct stones in unselected patients is feasible and safe. Received: 21 May 1996/Accepted: 10 March 1997     

澳大利亚微创胆道外科

目的 从20世纪末期以来,澳大利亚腹腔镜手术已经快速发展进步并且逐渐扩展到各个外科手术领域.一些外科医生也完成并发表了关于腹腔镜胆总管探查技术的报道.在本文中,作者介绍了目前澳大利亚的微创外科手术治疗胆管疾病的现状,包括：常规或选择性胆管造影;胰腺胆道疾病中ERCP的作用;腹腔镜胆总管探查术的手术技巧以及胆源性胰腺炎的治疗.作者还介绍了澳大利亚目前胆总管探查的现状,并且提到他们倾向于每例腹腔镜胆囊切除术都进行术中胆道造影.如果胆总管内发现小结石而且胆囊管足够粗,则进行经胆囊管的胆总管探查术.然而,如果狭窄的胆总管内有较大的结石,则进行术后ERCP治疗.作者还进一步介绍了胆道疾病相关的其他的微创治疗手术方法.总的来说,腹腔镜手术进行胆总管取石是可行和安全的.在有足够经验的医疗中心,这种手术方法可以常规使用.同时,成功进行腹腔镜胆总管探查术也需要多种方法综合进行.ERCP也没有被腹腔镜胆总管探查术所取代,而且成为一种重要的补充性的胆总管结石治疗方法.     

A "one-stage" laparoscopic procedure for treating choledocholithiasis.

OBJECTIVES: A minimally invasive approach is considered the treatment of choice for gallbladder stones. We report our experience with the treatment of choledocholithiasis. METHODS: From January 1993 to December 2002, 3118 patients underwent minimally invasive surgery for symptomatic gallstones, 2681 for gallbladder stones and 437 (14%) for cholecysto-choledocholithiasis. RESULTS: We performed endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy in 71 patients (18.7%) with high operative risks, transcystic clearance and transcystic drainage in 96 cases (26.2%) and transcholedochal clearance with a T-tube in 270 cases (73.8%). In 2 patients, residual stones were removed with endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Postoperative stay ranged from 4 days to 12 days. No morbidity or mortality occurred. CONCLUSION: In our experience, "one-stage" laparoscopic procedure for cholecystocholedocholithiasis is safe and effective in skilled hands.     

Stone clearance and risk factors for failure in laparoscopic transcystic exploration of the common bile duct

Background Laparoscopic cholecystectomy has become a gold standard globally. At the time of surgery, 5 to 10% of patients have coexisting stones in the common bile duct (CBD). There are several alternatives in treating these patients. We have chosen to try to extract the CBD stones at the primary operation by laparoscopic transcystic CBD exploration. Methods During the years 1994–2002 laparoscopic attempt of exploration of the CBD was made in 207 patients. Data was prospectively collected in a database, and was analyzed using unconditional logistic regression for risk factor analysis. Results In 155 of the 207 patients an attempt of transcystic CBD exploration was made and it was successful in 132 cases (85%). The median operating time was 184 minutes (range 89–384 minutes) and the median postoperative hospital stay was one day (range 1–31 days). The odds ratio for failure in stone clearance among patients with a bile duct diameter greater than 6 mm was 6.90 (95% confidence interval (CI): 0.87–54.61) compared to patients with a bile duct diameter of 6 mm or less. There was a significant threefold increase in risk among patients with stones of greater than 5 mm diameter compared to patients with stones 5 mm or less. Conclusions The laparoscopic transcystic exploration of the CBD had a high frequency of stone clearance and low morbidity in the present study. Moreover, large stones are a risk factor for failure in stone clearance.     

经胆囊管行术中胆道镜胆道探查87例分析

目的探讨经胆囊管行术中胆道镜胆道探壹的临床应用价值。方法对1997年9月至2004年12月82例开腹胆囊切除术病人经胆囊管行术中胆道镜胆道探壹术，5例腹腔镜下经胆囊管行胆道镜胆道探查术资料进行回顾性分析。结果病人结石清除率为100％。术后平均住院7．2d。结论在无禁忌证的前提下，无论是开腹还是腹腔镜手术。应首先考虑经胆囊管途径行胆道镜胆道探查取石术。     

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??Laparoscopic transcystic common bile duct exploration??A clinical analysis of 68 cases SUN Min??LIU Xun-qiang??TENG Yi-shan et al. Department of Hepatopancreatobiliary Surgery 3, the 2nd Affiliated Hospital of Kunming Medical University??Kunming 650101, China
Corresponding author?? TENG Yi-shan??E-mail??liuxunqiang1001@163.com
Abstract Objective To explore the curative effect and safety of laparoscopic transcystic common bile duct exploration in treating the small stones in common bile duct. Methods A total of 68 cases of laparoscopic transcystic common bile duct exploration were performed from August 2009 to August 2012 in Department of Hepatopancreatobiliary Surgery 3, the 2nd Affiliated Hospital of Kunming Medical University. The therapeutic effects of cases were studied. Results Among them, 62 cases were performed operation successfully. The success rate of operation was 91.12%. The mean operation time was 86 minute. Six cases were changed to laparoscopic common bile duct incision exploratory stone operation. Four cases were performed laparoscopic common bile duct exploration and primary suture, and 2 cases were performed T tube drainage. The transfer rate was 8.88%. All cases were placed abdominal cavity drainage tube pulled out after 2-6 days. The average hospitalization time was 6 days. No bile leak, stone residue, biliary tract infection, biliary tract bleeding complications occurred. Conclusion Laparoscopic transcystic common bile duct exploration has many advantages such as small trauma, short time??less complications, quick recovery??safe??low cost, safety and effective, etc. It is the ideal common bile duct exploration and stone operation. But its indications must be grasped strictly.     

The efficacy of preoperative endoscopic retrograde cholangiopancreatography in the detection and clearance of choledocholithiasis.

BACKGROUND AND OBJECTIVES: Endoscopic retrograde cholangiopancreaticography has been reported to have a high success rate in the detection and treatment of choledocholithiasis. Although there is growing enthusiasm for laparoscopic common bile duct clearance, many patients who present with gallbladder disease and suspected choledocholithiasis have endoscopic retrograde cholangiopancreatography performed with choledocholithiasis cleared if detected. These patients are then referred for laparoscopic cholecystectomy. The purpose of this study is to determine the efficacy of preoperative endoscopic retrograde cholangiopancreatography in the diagnosis and clearance of bile duct stones at our institution. METHODS: A retrospective review was performed of all patients at this institution who underwent preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis followed by laparoscopic cholecystectomy from January 1997 through July 1998. RESULTS: Common bile duct stones were detected endoscopically in 12 of 17 (71%) patients. We found serum bilirubin level to be the best predictor of choledocholithiasis. In 12 of 12 procedures, the endoscopist performed an endoscopic sphincterotomy with stone extraction and reported a fully cleared common bile duct. Intraoperative cholangiogram performed during subsequent cholecystectomy revealed choledocholithiasis in 4 of these 12 patients. Laparoscopic techniques successfully cleared the choledocholithiasis in 3 of these patients with open techniques necessary in the fourth. CONCLUSIONS: Our data suggests that even after presumed successful endoscopic clearance of the bile duct stones, many patients (33% in our series) still have choledocholithiasis present at the time of cholecystectomy. We recommend intraoperative cholangiography at the time of cholecystectomy even after presumed successful endoscopic retrograde cholangiopancreatography with further intervention, preferably laparoscopic, to clear the choledocholithiasis as deemed necessary.     

Laparoscopic cholecystectomy and choledocholithiasis.

Between November 1990 and March 1991, five patients with cholelithiasis and associated choledocholithiasis were treated by laparoscopic cholecystectomy and common-bile-duct exploration (CBDE). Three patients had a successful CBDE, but in two common-bile-duct stones had to be extracted surgically. Two patients had formal laparoscopic CBDE, and three patients had CBDE performed through the cystic duct. All patients recovered from surgery without complication. Laparoscopic CBDE is difficult to perform because of lack of adequate instrumentation and limited experience. Although the authors do not recommend that this procedure be performed widely at present, they believe it will eventually replace many open CBDEs. The authors review the pertinent literature and evaluate diagnostic means for preoperative and peroperative detection of choledocholithiasis. They discuss the alternatives to laparoscopic CBDE, their advantages and disadvantages. Finally, they summarize their own policy with respect to laparoscopic CBDE.     

Current management of common bile duct stones in a teaching community hospital

The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.