Laparoscopic common bile duct exploration

OBJECTIVE: To describe the technique of laparoscopic common bile duct exploration (LCBDE) with high clearance rates, low morbidity, and mortality rates. SUMMARY BACKGROUND DATA: LCBDE is well accepted by patients because treatment is obtained during the same anesthesia. If one stage therapy for gallstones and common bile duct stones provides success rates equivalent to those of the sequential approach, with lower costs, this should be considered the standard of care. METHODS: From September 1991 to March 2007, 5201 laparoscopic cholecystectomies were performed at S?o José Avaí Hospital. LCBDE was carried out in 481 patients (9.25%). RESULTS: Of 481 LCBDE, 225 (46.78%) were managed using a transcystic approach and 183 (38.05%) with choledochotomy (114 with transcystic choledochotomy and 69 with longitudinal opening of the common bile duct). Successful laparoscopic stone clearance was achieved in 468 (97.3%). An elective postsurgical endoscopic sphincterotomy were done on the 13 (2.70%) patients not cleared laparoscopically. Seven patients had unexpected retained stones. CONCLUSIONS: LCBDE during laparoscopic cholecystectomy solves 2 problems during the same anesthesia with high success rates and may be employed successfully.     

Laparoscopic common bile duct exploration

Background: Herein I describe my >12-year experience with laparoscopic common bile duct exploration (LCBDE). Methods: From 21 September 1989 through 31 December 2001, 3,580 patients presented with symptomatic biliary tract disease. Laparoscopic cholecystecomy (LC) was attempted in 3,544 of them (99.1%) and completed in 3,527 (99.5%). Laparoscopic cholangiograms (IOC) were performed in 3,417 patients (96.4%); in 344 cases (9.7%), the IOC was abnormal. Forty-nine patients (1.4%) underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP), and 33 patients (0.9%) underwent postoperative ERCP. LCBDE was attempted in 326 cases and completed in 321 (98.5%). It was successful in clearing the duct in 317 of the 344 patients with abnormal cholangiograms (92.2%). Results: The mean operating time for all patients undergoing LC with or without cholangiograms or LCBDE or other additional surgery was 56.9 min. Mean length of stay was 22.1 h. The mean operating time for LC only patients (n = 2530)—that is, those not undergoing LCBDE or any other additional procedure—was 47.6 min; their mean postoperative length of stay was 17.2 h. Ductal exploration was performed via the cystic duct in 269 patients, (82.5%) and through a choledochotomy in 57 patients (17.5%). T-tubes were used in patients in whom there was concern for possible retained debris or stones, distal spasm, pancreatitis, or general poor tissue quality secondary to malnutrition or infection. In cases where choledochotomy was used, a T-tube was placed in 38 patients (67%), and primary closure without a T-tube was done in 19 (33%). There were no complications in the group of patients who underwent choledochotomy and primary ductal closure without T-tube placement or in the group in whom T-tubes were placed. Conclusions: Common bile duct (CBD) stones still occur in 10% of patients. These stones are identified by IOC. IOC can be performed in >96.4% of cases of LC. LCBDE was successful in clearing these stones in 97.2% of patients in whom it was attempted and in 92.2% of all patients with normal IOCs. Most LCBDEs in this series were performed via the cystic duct because of the stone characteristics and ductal anatomy. Selective laparoscopic placement of T-tubes in patients requiring choledochotomy (67%) appears to be a safe and effective alternative to routine T-tube drainage of the ductal system. ERCP, which was required for 5.8% of patients with abnormal cholangiograms, and open CBDE, which was used in 2.0%, still play an important role in the management of common bile duct pathology. The role of ERCP, with or without sphincterotomy, has returned to its status in the prelaparoscopic era. LCBDE may be employed successfully in the vast majority of patients harboring CBD stones.     

Laparoscopic common bile duct exploration

Surgical Endoscopy -     

Laparoscopic common bile duct exploration

BACKGROUND: Laparoscopic common bile duct (CBD) exploration is gaining favor in the treatment of patients with gallstones and CBD stones. Our aim is to report our results with this procedure, focusing on the technical aspects. PATIENTS AND METHODS: All patients with proven CBD stones undergo laparoscopic transcystic CBD exploration, preferably, or a choledochotomy if the former is not feasible. According to CBD stone load and diameter, a biliary drainage tube is positioned for postoperative biliary decompression. RESULTS: Among 284 patients who underwent laparoscopic CBD exploration, 4 (1.4%) were converted to open surgery. Transcystic CBD exploration was feasible in 163 cases (58.2%), but a choledochotomy was required in 117 (41.8%). Biliary drains were positioned in 204 patients (72.8%). Minor complications included hyperamylasemia (11; 3.9%) and minor subhepatic bile collection (7; 2.5%). Major complications were bile leakage (5; 1.8%), hemoperitoneum from cystic artery bleeding (2; 0.7%), subhepatic abscess (2; 0.7%), acute pancreatitis (1; 0.3%), and jejunal perforation (1; 0.3%). Retained CBD stones in 15 patients (5.3%) were removed through the biliary drainage sinus tract (8) or after endoscopy and sphincterotomy (6). In one patient, a small stone passed spontaneously (overall success rate 94.6%). Death from a cardiovascular complication was observed in one elderly high-risk patient (0.3%). Recurrent ductal stones in 5 patients (1.8%) were treated with ERCP and endoscopic sphincterotomy. One patient with re-recurrent ductal stones underwent hepaticojejunostomy. CONCLUSIONS: Laparoscopic CBD exploration during LC in unselected patients solves two problems during the same anesthesia with high success rates (94.6%), low minor (6.4%) and major (3.8%) morbidity rates, and a low mortality rate (0.3%). Standardization of the technique is mandatory to achieve high success rates.     

Laparoscopic common bile duct exploration

In recent years, laparoscopic common bile duct exploration has become the procedure of choice in the management of choledocholithiasis in several laparoscopic centers. The increasing interest for this laparoscopic approach is due to the development of instrumentation and technique, allowing the procedure to be performed safely, and it is also the result of the revised role of endoscopic retrograde cholangiopancreatography, which has been questioned because of its cost, risk of complications and effectiveness. Many surgeons, however, are still not familiar with this technique. In this article we discuss the technique and results of laparoscopic common bile duct exploration. Both the laparoscopic transcystic approach and choledochotomy are discussed, together with the results given in the literature. When one considers the costs, morbidity, mortality and the time required before the patient can return to work, it would appear that laparoscopic cholecystectomy with common bile duct exploration is more favorable than open surgery or laparoscopic cholecystectomy with preoperative or postoperative endoscopic sphincterotomy. However, the technique requires advanced laparoscopic skills, including suturing, knot tying, the use of a choledochoscope, guidewire, dilators and balloon stone extractor. Although laparoscopic common bile duct exploration appears to be the most cost-effective method to treat common bile duct stones, it should be emphasized that this procedure is very challenging, and it should be performed by well-trained laparoscopic surgeons with experience in biliary surgery.     

腹腔镜下胆总管切开探查在胆管结石中的应用

目的 :总结腹腔镜下胆总管切开探查取石术的临床应用经验 ,探讨其手术方法 ,术中注意事项及临床应用的优缺点。方法 :腹腔镜下胆总管切开取石 ,T管引流或一期缝合。结果 :2 3例胆总管结石手术2 1例成功 ,2例中转开腹。结论 :腹腔镜下胆总管切开取石术应掌握适应证 ,才能使创伤减小 ,康复快且安全。     

Laparoscopic transcystic duct common bile duct exploration

The modern era of common bile duct (CBD) surgery started with Mirizzi, who introduced intraoperative cholangiography in 1932. Intraoperative choledoscopy had been developed as an adjunctive to intraoperative cholangiography, which helped to detect CBD stones in an additional 10% to 15% of instances that otherwise would have been missed. Findings have shown choledochoscopy to be an important technique for efficient and effective management of CBD stones. Efforts to treat patients with common duct stones in one session and to avoid the potential complications of endoscopic sphincterotomy resulted in several laparoscopic transcystic CBD (LTCBDE) techniques. The techniques of transcystic stone extraction include lavage, trolling with wire baskets or biliary balloon catheters, cystic duct dilation, biliary endoscopy, and stone retrieval with wire baskets under direct vision and antegrade sphincterotomy, lithotripsy, and catheter techniques. The indications for LTCBDE are filling or equivocal defects at cholangiography, stones smaller than 10 mm, fewer than 9 stones, and possible tumor. The contraindications are stones larger than 1 cm, stones proximal to the cystic duct entrance into the CBD, small friable cystic duct, and 10 or more stones. Experience with LTCBDE shows that the approach is applicable in more than 85% of cases, with a success rate of 85% to 95%. It also is shown to be more cost effective than postoperative endoscopic retrograde cholangiopancreatography. Recent developments in LTCBDE have focused mainly on implementation of robotically assisted surgery and new imaging methods such as magnetic resonance cholangiopancreatography with three-dimensional virtual cholangioscopy and three-dimensional ultrasound. Further technological advances will facilitate the application of laparoscopic approaches to the common duct, which should become the primary strategy for the great majority of patients.     

腹腔镜与传统开腹手术治疗胆总管结石的临床应用比较

目的比较腹腔镜胆囊切除＋胆总管切开探查取石术和传统开腹胆囊切除＋胆总管切开探查取石术的临床效果和医疗费用。方法55例胆总管结石患者分两组,A组25例行腹腔镜胆囊切除＋胆总管切开取石术;B组30例行传统开腹胆囊切除＋胆总管切开取石术。统计手术时间,术后开始下床活动时间,术后胃肠功能恢复时间,术后住院时间,术后并发症和总住院费用。结果两组患者都顺利完成手术,术后两组各有1例患者胆道造影残留结石,两组手术时间无显著差异,A组患者术后下床活动时间、胃肠功能恢复时间较B组患者早,术后A组住院时间较B组短,住院费用A组较B组增多。结论腹腔镜胆总管切开取石术完全能达到传统开腹胆道切开取石术的效果,并具有创伤小,痛苦少,恢复快的优点,是治疗胆总管结石的理想手术方式之一。     

Laparoscopic exploration of the common bile duct

Background: Bile duct clearance at open cholecystectomy had become normal surgical practice before the introduction of laparoscopic cholecystectomy. However, perceived technical difficulties have deterred many surgeons from treating common bile duct stones at the time of laparoscopic cholecystectomy. This has led to a reliance on preoperative clearance of ducts known to have stones and postoperative clearance of ducts found to have stones at operation or those that subsequently develop complications of retained stones. Methods: The authors describe a series of 120 consecutive bile duct explorations carried out between April 1991 and February 1997 in a series of 1,237 laparoscopic cholecystectomies. Results: Laparoscopic exploration and clearance of the bile ducts was achieved in 89% of cases in the whole series, and 97% success was attained in the last 60 cases, which also were associated with a decrease in operating time. Conclusions: We believe that for surgeons familiar with open common bile duct exploration and laparoscopic cholecystectomy, the next logical step is laparoscopic exploration of the common bile duct at the time of cholecystectomy, which is safe and readily mastered. Received: 15 December 1997/Accepted: 11 March 1998     

Laparoscopic common bile duct exploration.

Operative common bile duct exploration, performed in conjunction with cholecystectomy, has been considered the treatment of choice for choledocholithiasis in the presence of an intact gallbladder. With the advent of laparoscopic cholecystectomy, the management of common bile duct stones has been affected. More emphasis is being placed on endoscopic sphincterotomy and options other than operative common duct exploration. Because of this increasing demand, we have developed a new technique for laparoscopic common bile duct exploration performed in the same operative setting as laparoscopic cholecystectomy. A series of five patients who successfully underwent common bile duct exploration, flexible choledochoscopy with stone extraction, and T-tube drainage, all using laparoscopic technique, is reported. Mean postoperative length of hospital stay was 4.6 days. Outpatient T-tube cholangiography was performed in all cases and revealed normal ductal anatomy with no retained stones. Follow-up ranged from 6 weeks to 4 months, and all patients were asymptomatic and had normal liver function tests.     

Laparoscopic exploration of the common bile duct

Since the first laparoscopic common bile duct exploration in Hungary published in 1999 the authors use the technique themselves. We review and analyse our activity between 1 June 1999 and 31 August 2003. The minimally invasive approach was selected in twelve patients with obstructive jaundice for suspected bile duct stones. Eight of these patients underwent preoperative endoscopy, but either the number and/or size of stones or various complications prevented successful endoscopic stone extraction; five sphincterotomies--two followed by stenting--were performed. The four other patients did not consent to endoscopy. During surgery the biliary tract was visualised by choledochoscope (a bile duct endoscope with video connection) in four cases via the distended cystic duct and in eight cases via longitudinal choledochotomy. In one case there was no occlusion at all, in another one dilatation was performed because of a structure. In nine patients stones were removed either through the choledochotomy/cystic duct or by passing them into the duodenum. In one patient we converted to open procedure due to a stone impacted in the papilla of Vater. After choledochotomy intracorporal suturing and knot tying techniques were used to close the incision. On six occasions a cystic drain, three occasions a T-tube and on three occasions primary closure was used. Two bile leaks were treated by endoscopic stenting and in one patient a laparotomy was needed. There was no mortality. We believe that laparoscopic common bile duct exploration can be successful even in complicated situations.     

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.