Common bile duct exploration in the era of laparoscopic surgery
M. E. Stoker
Department of Surgery, Fallon Clinic, St. Vincent Hospital, Worcester.
OBJECTIVE: To review the treatment and outcome of patients with common bile
duct (CBD) stones who underwent cholecystectomy. DESIGN: Prospective series
of 700 consecutive laparoscopic cholecystectomies, with a mean follow-up of
22 months. SETTING: University-affiliated community hospital. PATIENTS:
Eighty patients with documented CBD stones during a 42-month period (July
1990 to January 1994). INTERVENTIONS: Laparoscopic CBD exploration (LCBDE)
was performed with either choledochotomy and T tube (n = 27) or transcystic
duct choledochoscopy (n = 33). Open CBDE (OCBDE) (n = 16) and endoscopic
sphincterotomy (n = 16) were also employed. MAIN OUTCOME MEASURES:
Documented removal of CBD stones and procedure-related complications.
RESULTS: Laparoscopic CBDE was successful in 60 (94%) of 64 attempted
cases. Mean operating time was 149 +/- 40 minutes and length of hospital
stay was 2.8 +/- 2.1 days. Six complications (10%) were recorded, including
three retained stones (5%). In 11 of 16 patients undergoing OCBDE, CBD
stones were discovered with intraoperative cholangiography after conversion
to laparotomy was needed for completion of the cholecystectomy. One OCBDE
was planned in a patient with suppurative cholangitis. Preoperative
endoscopic sphincterotomy (n = 11) was successful in four patients.
Postoperative endoscopic sphincterotomy (n = 5) was successful in four
patients. CONCLUSION: With a protocol of routine cholangiography, LCBDE,
and selective use of OCBDE (when LCBDE is not possible), the reliance on a
second procedure (endoscopic sphincterotomy) can be minimized. Laparoscopic
CBDE, a technically demanding operation, is possible at the time of
laparoscopic cholecystectomy in the majority of cases, with a low
complication rate and a short length of hospital stay.
