Laparoscopic management of common bile duct stones

We reviewed our experience with the management of common bile duct (CBD) stones in 100 consecutive patients treated laparoscopicaly during the past 9 years (1990—1998) and evaluated the advantages, disadvantages, and feasibility of the treatment, to elucidate reasonable therapeutic strategies for patients harboring CBD stones. We conclude that the most rational management of CBD stones is that which is decided according to the size of the CBD, which, in turn, depends on the size, number, and location of stones. The cystic duct in patients with a non‐dilated CBD is narrow, because the size of the CBD depends on the size and number of stones that have migrated through the narrow cystic duct, and the stones in the non‐dilated CBD are therefore usually small in size and number. Patients with a dilated CBD, however, are good candidates to undergo single‐stage laparoscopic treatment. In our Department, therefore, even if complete removal of stones has failed in patients with non‐dilated CBD, further choledochotomy is not carried out, and a C‐tube is placed through the cystic duct for a subsequent postoperative transduodenal approach, because laparoscopic transcystic CBD exploration and choledochotomy may not be always feasible in those patients with non‐dilated CBD, and spontaneous migration of small stones into the duodenum is frequently noted. In fact, some stones demonstrated on intraoperative cholangiograms were not revealed by postoperative cholangiography. In contrast, retained stones detected postoperatively were successfully removed by postoperative endoscopic sphincterotomy (EST), the endoscopic papillary balloon dilatation technique (EPBDT), or postoperative cholangioscopy (POCS) without any injury to the sphinter of Oddi. With this approach, we believe that the causes of stone recurrence can be avoided in the majority of cases.     

内镜扩约肌切开术治疗胆总管继发性结石

目的评价逆行胰胆管造影术（ＥＲＣＰ）和内镜括约肌切开术（ＥＳＴ）在腹腔镜胆囊切除前后诊断和治疗胆总管继发结石中的作用．方法采用ＥＲＣＰ和ＥＳＴ在ＬＣ术前或术后诊断和治疗胆总管继发结石２２８例,其中包括ＬＣ术前发现的１８５例和术后确诊的４３例．常规ＥＲＣＰ检查,证实胆总管内有结石后行ＥＳＴ．然后根据结石形态、大小和数目不同采取不同方法处理结石．①自然排石,适合于直径在０３ｃｍ～０８ｃｍ的结石;②取石网篮取石,适合于直径在０９ｃｍ～１５ｃｍ的结石;③碎石篮碎石,适宜直径大于１５ｃｍ以上的结石．结果全部２２８例患者中,ＥＳＴ成功２１７例（９５２％）,胆总管结石完全排出２０９例（９１７％）,发生各种并发症１９例（８８％）,主要并发症为急性胰腺炎、急性胆管炎和Ｏｄｄｉ扩约肌切口渗血,全部经非手术治疗愈合,无死亡病例．结论ＥＲＣＰ和ＥＳＴ是ＬＣ术前和术后诊治胆总管结石安全有效的方法之一．     

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.     

A Case of Post-Laparoscopic Cholecystectomy Bile Leakage from the Cystic Duct Treated by Endoscopic Nasobiliary Drainage without EST

Abstract: The patient was a 45 year old female with cholelithiasis who had undergone laparoscopic cholecystectomy. Bile leakage was detected from the site of Penrose drain insertion immediately after the operation. As no improvement of bile leakage was subsequently observed, ERCP (endoscopic retrograde cholangiopancreatography) was performed on the third postoperative day. Neither choledocholithiasis nor choledochal stricture was found and the diagnosis of bile leakage from the cystic duct stump was made. A 5Fr ENBD (endoscopic nasobiliary drainage)-tube without EST (endoscopic sphincterotomy) was inserted into the common bile duct, and bile leakage disappeared completely on the third day after insertion of the ENBD tube. Additional laparotomy, EST or biliary stenting was thereby avoided. Choledo-chography, via the ENBD-tube, showed no leakage of contrast material, the ENBD-tube was removed and the patient was discharged. ENBD should be considered as a method of treatment for management of bile leaks from the cystic duct stump.     

Surgery in biliary lithiasis: from the traditional"open" approach to laparoscopy and the"rendezvous" technique

BACKGROUND:According to the current literature, biliary lithiasis is a worldwide-diffused condition that affects almost 20% of the general population. The rate of common bile duct stones (CBDS) in patients with symptomatic cholelithiasis is estimated to be 10% to 33%, depending on patient's age. Compared to stones in the gallbladder, the natural history of secondary CBDS is still not completely understood. It is not clear whether an asymptomatic choledocholithiasis requires treatment or not. For many years, open cholecystectomy with choledochotomy and/or surgical sphincterotomy and cleaning of the bile duct were the gold standard to treat both pathologies. Development of both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery, together with improvements in diagnostic procedures, influ-enced new approaches to the management of CBDS in associ-ation with gallstones. DATA SOURCES: We decided to systematically review the lit-erature in order to identify all the current therapeutic options for CBDS. A systematic literature search was performed in-dependently by two authors using PubMed, EMBASE, Scopus and the Cochrane Library Central.RESULTS: The therapeutic approach nowadays varies great-ly according to the availability of experience and expertise in each center, and includes open or laparoscopic common bile duct exploration, various combinations of laparoscopic cholecystectomy and ERCP and combined laparoendoscopic rendezvous. CONCLUSIONS: Although ERCP followed by laparoscopic cholecystectomy is currently preferred in the majority of hospitals worldwide, the optimal treatment for concomitant gallstones and CBDS is still under debate, and greatly varies among different centers.     

Comparison between endoscopic papillary balloon dilatation and endoscopic sphincterotomy for the treatment of common bile duct stones

Background This study was designed to evaluate the therapeutic outcome and early postoperative complications, especially pancreatitis, of endoscopic papillary balloon dilation (EPBD) and endoscopic sphincterotomy (EST) in patients with common bile duct stones in our department. Methods One hundred eighty patients with common bile duct stones were randomized to undergo EPBD or EST. An 8-mm dilatation balloon was used for EPBD. Modified Cotton's criteria, in which relatively mild pancreatitis is also included as a complication, were used to determine the incidence of postoperative complications. Results The rate of complete removal of stones was significantly higher in the EST group (95.6%) than in the EPBD group (86.6%); for stones less than 10 mm in diameter, however, the rate with EPBD (93.8%) was almost equivalent to that with EST (98.1%). According to modified Cotton's criteria, the incidence of postoperative pancreatitis was significantly higher in the EPBD group (16.7%) than in the EST group (6.7%). Bleeding was encountered in one patient (1.1%) in the EST group, but in none in the EPBD group. No fatal complication occurred in either the EPBD or the EST group. Conclusions Although EPBD appears to be comparable to EST for removal of small common bile duct stones, mild postoperative pancreatitis is more likely to occur with EPBD than with EST.     

Common bile duct stones: management strategies in the laparoscopic era

We reviewed our experience with the treatment of common bile duct (CBD) stones in 70 patients by sequential endoscopic-laparoscopic management and single-stage laparoscopic treatment during the past 7 years. The advantages, disadvantages, and feasibility of the two procedures are discussed to elucidate therapeutic strategies for patients harboring gallbladder stones and associated choledocholithiasis. In 44 patients, sequential endoscopic-laparoscopic management was indicatedd, and was successful in 37 of them but, in seven patients endoscopic stone extraction could not be accomplished. Single-stage laparoscopic treatment was attempted in 26 patients. In practice, laparoscopic transcystic common duct exploration or choledochotomy may not always be feasible if the cystic duct or CBD are not dilated; there is a high risk of intraoperative CBD injury in such circumstances. Laparoscopic management was considered to be especially useful for the treatment of numerous, large or difficult stones, because stone removal could be succesfully performed without any injury to the papilla of Vater. This last issue is of particular importance in patients with dilated CBD, because insufficient opening of the ampulla of Vater made by endoscopic sphincterotomy (EST) may lead to stasis and reflux-related complications such as cholangitis and recurrent stones. We conclude that the most rational management of CBD stones should be decided according to the size of the CBD, which depends on the size, number, and location of stones. Patients with dilated CBD are indicated to under-go laparoscopic single-stage treatment and combined endoscopic-laparoscopic treatment may be best for patients with non-dilated CBD.     

Management of gallbladder and common bile duct stones: Laparoscopic cholecystectomy combined with preoperative endoscopic sphincterotomy versus open surgery

Laparoscopic cholecystectomy (LC) combined with preoperative endoscopic sphincterotomy (EST) is becoming more widely employed as a therapeutic option for the management of gallbladder stones (GBS) and common bile duct stones (CBDS). To compare the results of LC plus preoperative EST with the results of open surgery, in terms of morbidity, mortality, hospital stay, length of operation, and hospital cost, we reviewed the charts of 105 patients who had concomitant GBS and CBDS: in 34, preoperative EST had been attempted, and 71 had undergone open surgery. Twenty-six of the 71 patients who had undergone open cholecystectomy, common bile duct exploration, and T-tube placement were selected for comparison as a T-tube group, since they had exhibited no condition that contraindicated LC. EST was unsuccessful in 6 of the 34 patients in whom it was attempted, and all 6 underwent open surgery. Successful EST and duct clearance were achieved in 28 patients (82.4%); 4 of them had serious medical problems and were followed without operation, 7 underwent open cholecystectomy, and the remaining 17 underwent LC (LC-after-EST group). Total hospital stay was longest in the 6 patients who underwent open surgery because of unsuccessful EST, and their total hospital cost was significantly higher than that of the patients in the LC-after-EST group. Operation time, rate of early postoperative complications, and hospital stay were significantly lower in the LC-after-EST group than in the T-tube groups, although total hospital cost was not different. The combination of preoperative EST and LC is a safe and effective option for the management of GBS and CBDS. However, when EST is unsuccessful and the patient is switched to open surgery, the hospital stay is much longer and more costly than when EST and LC are successful. The patient should be informed of the disadvantages if EST should fail.     

How I do it — Laparoscopic Cholecystectomy

Abstract: One thousand consecutive patients underwent a laparoscopic cholecystectomy from September 1990 to January 1993 at our institution. A total of 435 presented with complications acute cholecystitis (83), common bile duct stones (61), or previous abdominal surgery (321). Of the 1,000 patients, 37 (3.7%) were converted to an open cholecystectomy, usually because of marked inflammation and unclear anatomy. There were no deaths and the total postoperative complication rate was 91 of 1,000 (9.1%). Major complications (1.1%) included 3 bile duct injuries, 2 postoperative bleedings, 5 residual common duct stones and 1 case of peritonitis caused by stone spillage. All bile duct injuries were detected and suspected in the operating room and repaired by a Roux-en-Y hepaticojejunostomy. Minor complications occurred in the remaining 80 patients(8.0%). The most common complication encountered was urinary retention (6.1%). Intraoperatively, the two-hand technique, electrosurgical dissection, selective cholangiography and selective use of closed drainage were used. When common bile duct stones were encountered during the performance of laparoscopic cholecystectomy, they were primarily managed by a simultaneous laparoscopic choledochotomy. These experiences suggested that the immediate detection of operative injury was very important to prevent later serious complications, and wider operative indications can be applied safely and carefully by trained general surgeons.     

Reoperation of biliary tract by laparoscopy： Experiences with 39 cases

AIM：To evaluate the safety and feasibility of biliary tract reoperation by laparoscopy for the patients with retained or recurrent stones who failed in endoscopic sphincterotomy.
METHODS：A retrospective analysis of data obtained from attempted laparoscopic reoperation for 39 patients in a single institution was performed, examining open conversion rates, operative times, complications, and hospital stay.
RESULTS：Out of the 39 cases, 38 （97%） completed laparoscopy, 1 required conversion to open operation because of difficulty in exposing the common bile duct. The mean operative time was 135 min. The mean post-operative hospital stay was 4 d. Procedures included laparoscopic residual gallbladder resection in 3 cases, laparoscopic common bile duct exploration and primary duct closure at choledochotomy in 13 cases, and laparoscopic common bile duct exploration and choledochotomy with T tube drainage in 22 cases. Duodenal perforation occurred in 1 case during dissection and was repaired laparoscopically. Retained stones were found in 2 cases. Postoperative asymptomatic hyperamlasemia occurred in 3 cases. There were no complications due to port placement, postoperative bleeding, bile or bowel leakage and mortality. No recurrence or formation of duct stricture was observed during a mean follow-up period of 18 mo.
CONCLUSION：Laparoscopic biliary tract reoperation is safe and feasible if it is performed by experiencedlaparoscopic surgeons, and is an alternative choice for patients with choledocholithiasis who fail in endoscopic sphincterectomy.     

A simple novel method of biliary drainage: gallbladder serosal wrapping after open choledochotomy

In this study, we developed a new, simple technique for biliary drainage after open choledochotomy of choledocholithiasis. After the absence of intraductal stones was established by operative cholangiography and cholangioscopy, preserved gallbladder serosal wrapping was performed by inclosing a polyethylene tube (C-tube), which was inserted from the cystic duct to optimal portion of choledochus, within the gallbladder bed, with continuous suture of the preserved serosa of the gallbladder using 4-0 absorbable thread. This method was used in the cases of 8 patients. There was neither bile leakage nor residual bile duct stones. The C-tube could be removed after 7 days following surgery. The average hospital stay was 12.3 +/- 6.6 days. We propose that this procedure would be very simple and useful, and it would significantly shorten hospital stays after open choledochotomy of choledocholithiasis.     

Evolution of endoscopic sphincterotomy

Endoscopic sphincterotomy (EST) is a non-surgical treatment for residual or relapsing common bile duct stones in patients with a history of cholecystectomy and/or choledochotomy. Indications for its use have gradually expanded and now include removal of choledochal stones prior to cholecystectomy and removal of large bile duct stones not originally considered suitable for endoscopic removal. EST is used world wide and it now plays an indispensable role in transpapillary diagnostic and therapeutic procedures such as insertion of thin caliber endoscopes into the biliopancreatic system and inserstion of endoprostheses for malignant biliary obstruction. However, some, doubts have been voiced about the extension of indications for EST. The problem of loss of function of the duodenal papilla, for example, is controversial. We summarize the circumstances surrounding the development of EST, the controversies that have occurred in the process of expanding EST indications, and the history of overcoming the technological problems with transpapillary endoscopic procedures. The importance of conducting well-controlled clinical trials to determine the usefulness of new techniques is discussed.     

Experience with Laparoscopic Cholecystectomy

Abstract: Laparoscopic cholecystectomy is rapidly replacing conventional cholecystectomy as the treatment of choice for gallbladder stone disease because of its lower morbidity. Our study began on 29th May, 1990 and continued until February 28th, 1991. 40 laparoscopic cholecystectomies were successfuly performed. 4 patients had an open cholecystectomy instead because of bleeding in 1, dense adhesions in 2 and Mirizzi's Syndrome in 1. The two technical measures taken to avoid common bile duct injury, were 1) exposure of both the cystic duct and cystic artery in the same field before clipping and division 2) demonstration of the continuity between the cystic duct and the Hartman's pouch. Technical difficulties often encountered were extensive adhesions, multiple or giant stones, inflamed gallbladder and a short or dilated cystic duct. There were 4 complications; one diaphragmatic injury resulting in a pneumothorax, one periumbilical subcutaneous emphysema and 2 mild bile leaks. On average, each patient required 1.3 intramuscular analgesic injections and spent 10 days recuperating in hospital. In Japan, many patients insist on staying longer in hospital. We believe that laparoscopic cholecystectomy will rapidly become the preferred treatment for gallbladder stone disease.     

腹腔镜胆囊切除术联合内镜下逆行胰胆管造影和十二指肠乳头括约肌切开术治疗胆囊结石合并肝外胆管结石患者疗效研究*

目的 探讨采用腹腔镜胆囊切除术(LC)、内镜下逆行胰胆管造影(ERCP)和十二指肠乳头括约肌切开术(EST)联合治疗胆囊结石合并肝外胆管结石患者的疗效。方法 2018年1月～2020年10月我院治疗的胆囊结石合并肝外胆管结石88例,在47例观察组采用LC联合ERCP和EST手术,在41例对照组采用开腹胆囊切除和胆总管探查取石治疗。采用视觉模拟评分法(VAS)评价术后疼痛程度。结果 两组结石一次性清除率比较无显著性差异(93.6%对95.1%,P>0.05);观察组术中出血量为(28.1±6.2)ml,显著少于对照组【(43.9±7.5)ml,P<0.05】,手术时间、术后禁食时间和住院时间分别为(105.7±25.5)min、(2.2±0.4)d和(7.6±1.0)d,显著短于对照组【分别为(130.2±26.7)min、(3.0±0.6)d和(12.7±1.3)d,P<0.05】;术后48 h和72 h VAS评分分别为(3.7±0.6)分和(2.5±0.5)分,均显著低于对照组【分别为(4.0±0.7)分和(2.9±0.5)分,P<0.05】;术后7 d,观察组血清ALT和AST水平分别为(46.1±5.6)U/L和(42.5±5.2)U/L,显著低于对照组【分别为(59.8±5.4)U/L和(64.7±5.1)U/L,P<0.05】,而血脂肪酶水平为(808.2±105.7)U/L,显著高于对照组【(721.9±103.0)U/L,P<0.05】;术后观察组并发症发生率为4.3%,显著低于对照组的14.1%(P<0.05)。结论 采用LC联合ERCP和EST治疗胆囊结石合并肝外胆管结石患者可促进术后恢复,改善肝功能,减少并发症的发生。     

Recurrence of biliary symptoms after endoscopic sphincterotomy for choledocholithiasis in patients with gall bladder stones

BACKGROUND: There are a few reports regarding the long-term results of endoscopic sphincterotomy (EST). However, little data is available on the recurrence of biliary symptoms after EST for choledocholithiasis, in patients with gall bladder stones. METHODS: All patients had gall bladder and common bile duct stones (n = 60; age 32-84 years, median age 55 years), and had received an EST. One group of these patients had a laparoscopic or open cholecystectomy (n = 39; group A), while the other group did not (n = 21; group B). The follow-up- period ranged from 5 to 54 months (average 22 months). RESULTS: Complications included the recurrence of common bile duct stones, recurrent acute cholecystitis, postoperative bile leakage and papillary stenosis. Nine patients (15%) had a recurrence of biliary symptoms. Two significant prognostic factors for the recurrence of biliary symptoms were identified by multivariate analysis; namely an intact gall bladder and a dilated common bile duct. The recurrence rate of biliary symptoms in group B was 20.4%, while in group A it was 10.3% (P< 0.01). Patients with a larger than average common bile duct diameter (mean diameter 14 mm) were more prone to the recurrence of symptoms than those with a smaller common bile duct diameter (mean diameter 10 mm, P< 0.016). The hospital stay period was 8.9 +/- 3.1 days in group A and 2.8 +/- 1.9 days in group B (P< 0.01). CONCLUSIONS: Biliary symptom recurrence occurred in a considerable proportion of patients after EST for the treatment of choledocholithiasis, in patients with gall bladder stones. The prognostic factors associated with the recurrence of biliary symptoms were an intact gall bladder and a dilated common bile duct diameter. Regardless of their short stay in hospital, non-cholecystectomy patients had a higher rate of recurrent biliary symptoms than cholecystectomy patients.     

Laparoscopic management of common bile duct stones: Study of 13 cases

In recent years, laparoscopic surgery for common bile duct (CBD) stones has been gaining wider acceptance. We report our experience with the laparoscopic management of CBD stones in 16 patients (9 males and 7 females; mean age, 62 years; range, 27–81 years). We considered two options for the laparoscopic procedures: (1) transcystic CBD exploration for those patients with fewer than 3 CBD stones, 5 mm or less in diameter, in whom the diameter of the cystic duct exceeded that of the CBD stones and (2) choledochotomy with T-tube drainage for other patients, unless a preoperative percutaneous transhepatic cholangio-drainage (PTCD) tube had been inserted. We successfully removed CBD stones by laparoscopic management in 13 of the 16 patients. The procedures employed were laparoscopic choledocholithotomy in 10 patients and laparoscopic transcystic CBD exploration and stone extraction in 3 patients. We converted to open choledochotomy in 3 patients, because of severe inflammation and dense adhesions due to acute cholecystitis in 2 patients and because of wide adhesions due to previous surgery in 1. We conclude that laparoscopic procedure is a safe and effective method for the removal of CBD stones.     

Antegrade biliary stenting versus T-tube drainage after laparoscopic choledochotomy--a comparative cohort study

BACKGROUND/AIMS: Laparoscopic exploration of the common bile duct (LECBD) has been proven to be an effective and preferred treatment approach for uncomplicated common bile duct stones. However there is still controversy regarding the choice of biliary decompression after laparoscopic choledochotomy. METHODOLOGY: This is a retrospective comparison between the use of antegrade biliary stenting and T-tube drainage following successful laparoscopic choledochotomy. During the period between January 1995 and July 2003, biliary decompression was achieved by either antegrade biliary stenting or T-tube drainage based on the discretion of the operating surgeon. For antegrade biliary stenting, a 10-Fr Cotton-Leung biliary stent was inserted through the choledochotomy and passed down across the papilla. The stent position was confirmed by on-table choledochoscopy before interrupted single-layered closure of the common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the stent 4 weeks after operation and at the same time to check for any residual stones or other complications like stricture or leak. In the T-tube group, a 16-Fr latex T-tube was used and the long limb was brought out through the subcostal trocar port followed by the same method of bile duct closure. Cholangiogram through the T-tube was performed on day 7 and the tube would be taken off 1 week later (about 2 weeks after operation) if the cholangiogram did not reveal any abnormality. The two groups were compared according to the demographic data, operation time, length of hospital stay and complication rates. RESULTS: During the study period, 108 laparoscopic explorations of the common bile duct were performed in our centre of which 95 were attempted laparoscopic choledochotomies and 13 were transcystic duct explorations. Of the 95 patients with attempted laparoscopic choledochotomy, there were 9 open conversions, 17 laparoscopic bilioenteric bypasses and 6 primary closures of the common bile duct. All of these patients together with those receiving transcystic duct explorations were excluded and the remaining 63 patients having postoperative bile diversion by either antegrade biliary stenting or T-tube drainage were included in this study. Bile diversion was achieved by antegrade biliary stenting in 35 patients whereas 28 patients had T-tube drainage. There was no difference between the two groups in terms of age, clinical presentation, bilirubin level, length of hospital stay, follow-up duration, common bile duct size, size of common bile duct stones, incidence of residual/recurrent stone and complication rate. It was observed that more patients in the stenting group developed bile leak (14.2% vs. 3.5%) and required more intramuscular pethidine injections (182.86 +/- 139.30 vs. 92.81+/-81.15mg, P=0.000). On the other hand, the T-tube group had longer operation time (141.4+/-45.1 vs. 11 1.1+/-33.9 minutes, P=0.006) and had a longer postoperative hospital stay (10.0+/-7.4 vs. 8.8+/-9.3 days, P=0.020) reaching statistical significance. CONCLUSIONS: Postoperative bile diversion by antegrade biliary stenting after laparoscopic choledochotomy is shown to shorten operation duration and postoperative stay as compared to T-tube drainage, but the problem of bile leak needs further refinement of insertion technique.     

ENDOSCOPIC NASOBILIARY GALLBLADDER DRAINAGE AFTER ENDOSCOPIC SPHINCTEROTOMY IN PATIENTS WITH ACUTE CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

A 77‐year‐old man was admitted for the treatment of obstructive jaundice and right hypochondralgia with high fever. An abdominal computed tomography revealed common bile duct stones and acute cholecystitis with gallstones. Magnetic resonance cholangiopancreatography revealed stones in the common bile duct. Endoscopic retrograde cholangiopancreatography also revealed stones in the common bile duct, and immediately endoscopic sphincterotomy was performed. After lithotripsy of the bile duct, continuous endoscopic nasogallbladder drainage was performed successfully. There was severe pus in the gallbladder. Next day, the patient was doing well; there was no pain and fever was down.     

Laparoscopy in cholecysto-choledocholithiasis

Gallstone disease is one of the most common problems in the gastroenterology and is associated with significant morbidity. It may present as stones in the gallbladder (cholecystolithiasis) or in the common bile duct (choledocholithiasis). At the end of the 1980s laparoscopy was introduced and first laparoscopic cholecystectomy was performed in 1985. The laparoscopic technique for removing the gallbladder is the current treatment of choice, although indications for open surgery exist. To perform laparoscopic cholecystectomy as safe as possible multiple safety measures were developed. The gold standard for diagnosing and removing common bile duct stones is Endoscopic Retrograde Cholangiopancreatography (ERCP). The surgical treatment option for choledocholithiasis is laparoscopic cholecystectomy with common bile duct exploration. If experience is not available, than ERCP followed by elective cholecystectomy is by far the best therapeutic modality. The present review will discuss the use, benefits and drawbacks of laparoscopy in patients with cholecystolithiasis and choledocholithiasis.     

Laparoscopic C-tube drainage via cystic duct following common bile duct exploration

Laparoscopic common bile duct (CBD) exploration has come into practice with the development of laparoscopic techniques and instrumentation. However, the use of a T-tube for biliary drainage lessens the advantages of laparoscopic surgery, i.e., short hospital stay and good cosmesis. We have performed CBD exploration by laparoscopic chledochotomy followed by transcystic biliary drainage using a 6 French vinyl tube (C-tube) instead of a T-tube and primary closure of the choledochotomy. The C-tube could be removed within 7 days postoperatively because the cystic duct was ligated with an elastic thread. Twelve patients with CBD stones were successfully treated by this new technique and there was no morbidity attributable to the procedure.