The significance of cystic duct stones encountered during laparoscopic cholecystectomy

Abstract

Background

Cystic duct stones (CDS) are occasionally encountered during laparoscopic cholecystectomy (LC). They may be noticed during the dissection of the cystic pedicle or seen to extrude from the cystic duct (CD) when it is divided or opened to perform the intraoperative cholangiogram (IOC). The procedures for dealing with CDS range from the simple removal of stones that fall out when the duct is opened to incising the duct over an impacted stone to facilitate its removal or converting to open surgery due to a large stone in a CD adherent to the bile duct (e.g., Mirizzi syndrome). Therefore, we set out to establish criteria that might be predictive of CDS, to examine the technical problems caused by them, to look for the most effective ways of avoiding adverse consequences, especially the risk of missing bile duct stones.

Methods

We performed a review and analysis of a database that included preoperative, operative, and postoperative data for all patients treated at our hospital who were found to have CDS.

Results

In a series of 520 LC performed over a period of 5 years, 64 cases of CDS were documented (12.3%). The preoperative risk factors in 45 of these cases (70.3%) were recent sever acute pain with or without liver function test (LFT) derangement (34.3%), jaundice (14%), pancreatitis (14%), and previous acute cholecystitis (7.8%). At operation, a single stone was found in the CD in 64% of the cases; multiple stones were found in 36%. Dissection of the pedicle was difficult in 21 cases and had to be carried out fundus-first in four cases. The CD was reported to be wide in 18 cases; five of them eventually needed to be closed with endoloops. Operative difficulty was reported in three of 19 cases where there were no preoperative risk factors. Simple removal of the stones was possible in most cases. CDS needed be crushed, the CD incised, or the procedure converted to open in only five cases (7.8%). IOC was attempted in all cases; it was normal in 39 (61%) and failed in two cases (3%). Eighteen patients (28%) were found to have bile duct stones; another five (7.8%) had CBD dilation or debris indicating possible recent passage of stones. Fourteen transcystic and nine direct bile duct explorations were performed.

Conclusion

Some CDS may slip from the gallbladder into the CD or the CBD during dissection. Careful retraction and manipulation should therefore be done to minimize this risk. Most CDS are easy to deal with, but some of them can result in increased operative difficulty. If IOC is not carried out on a routine basis, it becomes mandatory if CDS are encountered because ≤35% of them may be associated with bile duct stones.