Advertisement

Laparoscopic common bile duct exploration

  • J. B. PetelinEmail author
Original article

Abstract

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.

Keywords

Lapraroscopic cholecystectomy Common bile duct Cholelithiasis Cholecystitis Laparoscopic common bile duct exploration Endoscopic retrograde cholangiography Sphincterectomy Biliary tract disease 

References

  1. 1.
    Nahrwold, D 1986The biliary system.Sabiston, X eds. Textbook of surgery.WE SaundersPhiladelphiaGoogle Scholar
  2. 2.
    Way, LW, Admirand, WJ, Dunphy, JE 1972Management of choledocholithiasis.Ann Surg176347359PubMedGoogle Scholar
  3. 3.
    Beal, J 1984Historical perspective of gallstone disease.Surg Gynecol Obstet158181189Google Scholar
  4. 4.
    Escat, J, Fourtanier, G, Maigne, C, Vaislic, C, Fournier, D, Prevost, F 1985Choledochoscopy in common bile duct surgery for choledocholithiasis: a must.Am Surg51166167PubMedGoogle Scholar
  5. 5.
    Fink, AS 1993Current dilemmas in management of common duct stones.Surg Endosc7285291PubMedGoogle Scholar
  6. 6.
    Pappas, TN, Slimane, TB, Brooks, DC 1990100 consecutive common duct explorations without mortality.Ann Surg211260262PubMedGoogle Scholar
  7. 7.
    Fink, AS 1993To ERCP or not to ERCP? That is the question.Surg Endosc7375376PubMedGoogle Scholar
  8. 8.
    Petelin J (1994) Laparoscopic common bile duct exploration: evolution of a protocol which minimizes the need for ERCP. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Mashville, TM, USA 18 April 1994Google Scholar
  9. 9.
    Petelin, J 1991Laparoscopic approach to common duct pathology.Surg Laparosc Endosc13341PubMedGoogle Scholar
  10. 10.
    Hunter, J 1992Laparoscopic transcystic common bile duct exploration.Am J Surg1635358PubMedGoogle Scholar
  11. 11.
    Carroll, BJ, Phillips, EH, Daykhovsky, L, Grundfest, WS, Gersham, A, Fallas, M, Chandra, M 1992Laparoscopic choledochoscopy: an effective approach to the common duct.J Laparoendosc Surg21521PubMedGoogle Scholar
  12. 12.
    Sackier, JM, Berci, G, Pas-Partlow, M 1991Laparoscopic transcystic choledochotomy as an adjunct to laparoscopic cholecystectomy.Am Surg57323326Google Scholar
  13. 13.
    Jacobs, M, Cerdeja, JC, Goldstein, HS 1991Laparoscopic choledocholithotomy .J Laparoendosc Surg17982PubMedGoogle Scholar
  14. 14.
    Quattlebaum, JK, Flanders, HD 1991Laparoscopic treatment of common bile duct stones.Surg Laparosc Endosc12632PubMedGoogle Scholar
  15. 15.
    Appel, S, Krebs, H, Fern, D 1992Techniques for laparoscopic cholangiography and removal of common duct stones.Surg Endosc6134137PubMedGoogle Scholar
  16. 16.
    Birkett, D 1992Technique of cholangiography and cystic-duct choledochoscopy at the time of laparoscopic cholecystectomy for laser lithotripsy.Surg Endosc6252254PubMedGoogle Scholar
  17. 17.
    Fletcher, D, Jones, RM, O’Riordan, B, Hardy, KJ 1992Laparoscopic cholecystectomy for complicated gallstone disease.Surg Endosc6179182PubMedGoogle Scholar
  18. 18.
    Dion, YM, Morin, J, Dionne, G, Dejoie, C 1992Laparoscopic cholecystectomy and choledocholithiasis.Can J Surg356774PubMedGoogle Scholar
  19. 19.
    Arregui, M, Davis, CJ, Arkush, AM, Nagan, RF 1992Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis.Surg Endosc61015PubMedGoogle Scholar
  20. 20.
    Cotton, PB 1984Endoscopic management of bile duct stones (apples and oranges)Gut25587597PubMedGoogle Scholar
  21. 21.
    Carr-Locke, DL 1990Acute gallstone pancreatitis and endoscopic therapy.Endoscopy22180183PubMedGoogle Scholar
  22. 22.
    Vitale, GC, Larson, GM, Wieman, TJ, Cheadle, WG, Miller, FB 1993The use of ERCP in the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy.Surg Endosc7911PubMedGoogle Scholar
  23. 23.
    Petelin, J 1993Laparoscopic approach to common duct pathology.Am J Surg165487491PubMedGoogle Scholar
  24. 24.
    Franklin, ME, Pharand, D 1994Laparoscopic common bile duct exploration.Surg Laparosc Endosc4119124PubMedGoogle Scholar
  25. 25.
    Phillips, E, Carroll, BJ, Pearlstein, R, Daykhovsky, L, Fallas, MJ 1993Laparoscopic choledochoscopy and extraction of common bile duct stones.World J Surg172228PubMedGoogle Scholar
  26. 26.
    Petelin, J 1993Clinical results of common bile duct exploration.Endosc Surg Allied Technol1125129PubMedGoogle Scholar
  27. 27.
    O’Doherty, D, Neoptolemos, J, Carr-Locke, D 1986Endoscopic sphincterotomy for retained common bile duct stones in patients with T-tube in situ in the early postoperative period.Br J Surg73454456Google Scholar
  28. 28.
    Broughman, T, Sivak, M, Herman, R 1985The management of retained and recurrent bile duct stones.Surgery98746751PubMedGoogle Scholar
  29. 29.
    Petelin, J 1990The argument for contact laser laparoscopic cholecystectomy.Clin Laser Monthlyxx7174Google Scholar
  30. 30.
    Petelin J (1992) Laparoscopic common duct exploration. American College of Surgeons (ACS) Motion Picture Library. 16-min comprehensive video presented at the ACS Annual Meeting, October 1992, and selected for addition to the library of the collegeGoogle Scholar
  31. 31.
    Kitano, S, Iso, Y, Moriyama, M, Sugimachi, K 1993A rapid and simple technique for insertion of a T-tube into the minimally incised common bile duct at laparoscopic surgery.Surg Endosc7104105PubMedGoogle Scholar
  32. 32.
    Mooney, MJ, Deyo, G, O’Reilly, MJ 1992T-tube placement during laparoscopic cholecystectomy .Surg Endosc632PubMedGoogle Scholar
  33. 33.
    Petelin, JB 1996Laparoscopic ductal stone clearance: transcystic approach,Berci, GCuschieri, A eds. Bile ducts and bile duct stones,WB SaundersPhiladelphia97108Google Scholar
  34. 34.
    Reddick, EJ, Olsen, DO, Daniell, JF, Saye, WB, McKernan, B, Miller, W, Hoback, M 1989Laparoscopic laser cholecystectomy .Laser Med Surg News Advxx3840Google Scholar
  35. 35.
    Klaiber, C, Metzger, A, Petelin, J 1993Laparoscopic cholecystectomy.Manual of laparoscopic surgery.Verlag Hans Huber97148Google Scholar
  36. 36.
    Ferzli, GS, Massaad, A, Ozuner, G, Worth, MH 1992Laparoscopic exploration of the common bile duct.Surg Gynecol Obstet174419421Google Scholar
  37. 37.
    Stoker, ME, Leveillee, RJ, McCann, JC, Maini, BS 1991Laparoscopic common bile duct exploration.J Laparoendosc Surg1287293PubMedGoogle Scholar
  38. 38.
    DePaula, AL, Hashiba, K, Bafutto, M, Zago, R, Grecco, E 1993Laparoscopic treatment of choledocholithiasis.Surg Laparosc Endosc3157160PubMedGoogle Scholar
  39. 39.
    Gagner M, Deslandres E, Pomp A, Rheault M, Potvin C, Leduc R (1993) Double endoscopy: the role of intraoperative ERCP during laparoscopic cholecystectomy for choledocholithiasis. Proceedings of the 3rd International Congress of Laparoscopic Surgery, Brazil, 1993, pp 126–127Google Scholar
  40. 40.
    Shimi, S, Banting Fracs, S, Cuschieri, A 1992Transcystic drainage after laparoscopic exploration of common bile duct .Min Inv Ther1273276Google Scholar
  41. 41.
    Williams, JAR, Treacy, PJ, Sidey, CS,  et al. 1994Primary duct closure versus T-tube drainage following exploration of the common bile duct.Aust N Z J Surg64823826PubMedGoogle Scholar
  42. 42.
    Bernstein, DE, Goldberg, RI, Unger, SW 1994Common bile duct obstruction following T-tube placement at laparoscopic cholecystectomy.Gastrointest Endosc40362365PubMedGoogle Scholar
  43. 43.
    Elewaut, A, de Vos, M, Huble, F, de Cock, J 1989Unusual migration of a straight Amsterdam-type endoprosthesis for bile duct stones.Am J Gastroenterol84674676PubMedGoogle Scholar
  44. 44.
    Kram, HB, Garces, MA, Klein, SR, Shoemaker, WC 1985Common bile duct anastomosis using fibrin glue.Arch Surg12012501256PubMedGoogle Scholar
  45. 45.
    Lange, V, Rau, HG, Schardey, HM, Meyer, G 1993Laparoscopic stenting for protection of common bile duct sutures.Surg Laparosc Endosc3466469Google Scholar
  46. 46.
    Kelly, TR, Fink, JA 1983A new inflatable T-tube for completion cholangiography .Surg Gynecol Obstet157374376Google Scholar
  47. 47.
    Jacob, ET, Bronsther, B 1988A double ballooned inflatable and collapsible T-tube for selective proximal or distal cholangiography.Surg Gynecol Obstet1668586Google Scholar
  48. 48.
    Fine, AP 1993Laparoscopic, wire-guided insertion of biliary T-tubes.Surg Laparosc Endosc3147148Google Scholar
  49. 49.
    Kitano, S, Iso, Y, Moriyama, M, Sugimachi, K 1993A rapid and simple technique for insertion of a T-tube into the minimally incised common bile duct at laparoscopic surgery.Surg Endosc7104105PubMedGoogle Scholar
  50. 50.
    Lezoche, E, Paganini, AM, Guerrieri, M 1996A new T-tube applier in laparoscopic surgery.Surg Endosc10445448CrossRefPubMedGoogle Scholar
  51. 51.
    Lygidakis, NJ 1983Choledochotomy for biliary lithiasis: T-tube drainage or primary closure—effects on postoperative bacteremia and T-tube bile infection.Am J Surg146254256PubMedGoogle Scholar
  52. 52.
    Lygidakis, NJ 1983Operative risk factors of cholecystectomy–choledochotomy in the elderly.Surg Gynecol Obstet157l519Google Scholar
  53. 53.
    Lygidakis, NJ 1984Incidence of bile infection in biliary lithiasis. Effects on postoperative bacteremia of choledochoduodenostomy, T-tube drainage, and primary closure of the common bile duct after choledochotomy—a prospective trial.Am Surg50236240PubMedGoogle Scholar
  54. 54.
    Koivusalo, A, Makisalo, H, Talja, A,  et al. 1996Bacterial adherence and biofilm formation on latex and silicone T-tubes in relation to bacterial contamination of bile.Scand J Gastroenterolxx398403Google Scholar
  55. 55.
    Horgan, PG, Campbell, AC, Gray, GR, Gillespie, G 1989Biliary leakage and peritonitis following removal of T tubes after bile duct exploration.Br J Surg7612961297PubMedGoogle Scholar
  56. 56.
    Galan, CP, Alonso, AC 19xxBile leakage after removal of T tubes from the common bile duct.Br J Surg771075Google Scholar
  57. 57.
    Ryttov, N, Rasmussen, L, Pedersen, SA, Oster-Jorgensen, E 198999m Tc-labelled HIDA scintigraphy in assessment of bile leakage after removal of T tube from the common bile duct .Br J Surg761319PubMedGoogle Scholar
  58. 58.
    Thors, H, Gudjonsson, H, Oddsson, E, Cariglia, N 1994Endoscopic retrieval of a biliary T-tube remnant.Gastrointest Endosc40241242PubMedGoogle Scholar
  59. 59.
    Gillatt, DA, May, RE, Kenedy, R, Longstaff, AJ 1985Complications of T-tube drainage of the common bile duct.Ann R Coll Surg Engl67369371Google Scholar
  60. 60.
    Norrby, S, Heuman, R, Anderberg, B, Sjodahl, R 1988Duration of T-tube drainage after exploration of the common bile duct.Acta Chir Scand154113115PubMedGoogle Scholar
  61. 61.
    Cohen, Z, Rosenman , H,  et al. 1986Transient elevation of serum alkaline phosphatase after choledochotomy and T-tube placement.J Clin Gastroenterol8495496PubMedGoogle Scholar
  62. 62.
    Lygidakis, NJ 1993Hazards following T-tube removal after choledochotomy .Surg Gynecol Obstet163153155Google Scholar
  63. 63.
    Thors, H, Gudjonsson, H, Oddsson, E, Cariglia, N 1994Endoscopic retrieval of a biliary T-tube remnant.Gastrointest Endosc40241242PubMedGoogle Scholar
  64. 64.
    Payne, RA, Woods, WGA 1986Primary suture or T-tube drainage after choledochotomy.Ann R Coll Surg Engl68196198PubMedGoogle Scholar
  65. 65.
    Shyr-Ming sheen-Cheng, ., Chou, F. 1990Choledochotomy for biliary lithiasis: is routine T-tube drainage necessary? A prospective controlled trial.Acta Chir Scand156387390PubMedGoogle Scholar
  66. 66.
    Petelin JB, Lechleitner RA (1997) Laparoscopic choledochotomy without T-tube drainage is effective and safe. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), 1997Google Scholar
  67. 67.
    Tarnasky, PR, England, RE, Lail , LM,  et al. 1995Cystic duct patency in malignant obstructive jaundice: an ERCP-based study relevant to the role of laparoscopic cholecystojejunostomy.Ann Surg221265271PubMedGoogle Scholar
  68. 68.
    Schob, OM, Schmid, RA, Morimoto, AK,  et al. 1997Laparoscopic Roux-en-Y choledochojejunostomy.Am J Surg173312319CrossRefPubMedGoogle Scholar
  69. 69.
    Farello, GA, Cerofolini, A, Bergamaschi, G,  et al. 1993Choledochoduodenal anastomosis by laparoscopy.J Chir Paris130226230PubMedGoogle Scholar
  70. 70.
    Traverso, LW, Berci, G, , Cuschieri, A 1996A cost-effective approach to the treatment of common bile duct stones with surgical versus endoscopic techniques.Bile ducts and bile duct stones.WB SaundersPhiladelphia154l60Google Scholar
  71. 71.
    Shapiro, SJ, Gordon, LA, Daykhovsky, L,  et al. 1991Laparoscopic exploration of the common bile duct: experience in 16 selected patients.J Laparoendosc Surg6333341Google Scholar
  72. 72.
    Fielding, GA, O’Rourke, NA 1993Laparoscopic common bile duct exploration.Aust N Z J Surg63113115PubMedGoogle Scholar
  73. 73.
    Fletcher, DR 1993Common bile duct calculi at laparoscopic cholecystectomy: a technique for management.Aust N Z J Surg63710714PubMedGoogle Scholar
  74. 74.
    DePaula, AL, Hashiba, K, Bafutto, M 1994Laparoscopic management of choledocholithiasis.Surg Endosc813991403PubMedGoogle Scholar
  75. 75.
    Phillips, EH, Rosenthal, RJ, Carroll , BJ,  et al. 1994Laparoscopic trans-cystic duct common bile duct exploration.Surg Endosc813891394PubMedGoogle Scholar
  76. 76.
    Dion, YM, Ratelle, R, Morin , J,  et al. 1994Common bile duct exploration: the place of laparoscopic choledochotomy.Surg Laparosc Endosc6419424Google Scholar
  77. 77.
    Ferzli, GS, Massaad, A, Kiel, T,  et al. 1994 The utility of laparoscopic common bile duct exploration in the treatment of choledocholithiasis.Surg Endosc8296298PubMedGoogle Scholar
  78. 78.
    Franklin, ME, Pharand, D, Rosenthal, D 1994Laparoscopic common bile duct exploration .Surg Laparosc Endosc2119124Google Scholar
  79. 79.
    Khoo, DE, Walsh, CJ, Cox, MR,  et al. 1996Laparoscopic common bile duct exploration : evolution of a new technique.Br J Surg83341346PubMedGoogle Scholar
  80. 80.
    Berthou, JC, Drouard, F, Charbonneau, P, Moussalier, K 1997Laparoscopic management of common bile duct stones: technique and results about 200 cases.Eur J Celiosurg12230Google Scholar

Copyright information

© Springer-Verlag 2003

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of Kansas School of Medicine, Kansas City, KS 66104USA

Personalised recommendations