Introduction

Laparoscopic common bile duct exploration was first reported in the early 90′. Although this procedure has proved beneficial, the widespread adoption of laparoscopic common bile duct exploration is limited because of the technical complex, the need for specialized instruments (choledochoscope), and limited exposure and training of the surgical team to LCBDE.

Most of CBD stones can be managed by ERCP. LCBDE is mostly performed in patients with concomitant gallstones and CBD stones.

Patient Selection

Laparoscopic choledochotomy (LCD) is indicated for:

  • Gallstones with concomitant CBD stones.

  • CBD stones detected during cholecystectomy.

  • CBD stones that failed to endoscopic approach (inaccessibility of the scope, large CBD stones, multiple CBD stones).

  • Multiple primary CBD stones and intrahepatic stones.

Laparoscopic choledochotomy is recommended for patients with CBDs diameter more than 7 mm to reduce risk of postoperative stricture [1].

Procedure

Operating Room Setup, Patient Positioning, and Setting Surgical Team

Patient is placed in supine reverse Trendelenburg position. The arms should be tucked at the patient’s sides.

10 mm laparoscope of 30° or 45° is used.

Operating room setup is as in Fig. 1.

Fig. 1
A flat-lay image of an operating room setup where the patient with the stomach open for a surgical procedure is surrounded by surgeons and equipment or devices.

OR setup

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Technique

Trocar Placement

Trocar sites are as in (Fig. 2).

Fig. 2
An image of the trocar position on the stomach of a patient with parts labeled 5 millimeters, 5 millimeters, 10 millimeters, and 10 millimeters.

Trocar position

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Choledochotomy

First, hepatoduodenal ligament is exposed. CBD is the most lateral and superficial tubular structure in hepatoduodenal ligament. It is recommended that we should clear fat tissue to expose anterior CBD wall. If the location of CBD is not clear, aspiration of bile by a narrow-gauge needle may help. A longitudinal incision of 1–2 cm is made on the anterior CBD wall. Limitation of using surgical energy when opening the CBD is essential to avoid late stricture of CBD due to thermal injury. We often use needle tip electrocautery as in Fig. 3. Scissors without cautery is an alternative choice. Stay sutures may facilitate CBD exposure for opening. Bile culture should be done when necessary.

Fig. 3
A photograph of a surgical procedure where crossing vessels on an anterior wall is represented.

crossing vessels on CBD anterior wall

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Exploration of Bile Ducts and Stone Removal

After choledochotomy, small stones can be washed out using an irrigator or flushing water through a rubber catheter. High pressure during irrigation should be avoided in case of cholangitis.

Choledochoscope is very useful to inspect the CBD and intrahepatic bile ducts for stones and stricture (Fig. 4). The choledochoscope should be introduced through a plastic trocar located at the epigastric region, above the opening of the CBD to minimize excessive angulation of the choledochoscope during manipulation. When exploration demonstrates stones, basket or balloon catheter will be used to extract stones. In case of large or impacted stones, fragmentation is necessary. Electro-hydraulic lithotripsy or laser lithotripsy can be used. We prefer to use electro-hydrolic lithotripsy for fragmentation of bile duct stones because it is faster and less expensive compared to laser. Fragments will be removed by basket or balloon or flushing via a plastic catheter. With respect to acute cholangitis, there is higher risk of hemobilia when performing multiple lithotripsy. Hence, we should only address stones that cause obstruction. Residual stones should be removed via T-tube tract after 3–4 weeks by percutaneous cholangioscopy.

Fig. 4
A photograph of a spot made through a choledochoscope.

Choledochoscopy

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Stone forceps can be applied through 5 mm epigastric opening after removing the trocar to extract CBD stones as in Fig. 5. This modification facilitates the extraction of CBD stones especially large stones or multiple stones which is more common in Asia. Stones extracted are placed in a plastic bag. Gas loss when using stone forceps is insignificant.

Fig. 5
The left photograph is a surgical procedure of extracting stones, while the right picture depicts surgeons doing a procedure in the trocar position of the patient.

Stones extraction by forceps

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Closure of CBD

Closure of CBD incision can be done with or without biliary drainage. CBD closure without biliary drainage is called primary closure. Biliary drainage can be performed with T-tube (external drainage) or internal stent (internal drainage). With regard to internal stent placement, a subsequent endoscopic session is required to remove it. T-tube placement provides a T-tube tract through which postoperative percutaneous exploration of the bile ducts or residual stone management by choledochoscopy is enabled.

Primary closure: There is evidence that this technique has benefits as compared to biliary drainage such as reducing hospital stay, operating time, and overall cost. Primary closure is indicated in selected patients without acute cholangitis, without distal CBD obstruction, and complete clearance of bile duct stones [2].

Suturing in a continuous or interrupted fashion with absorbable 3.0 or 4.0 suture is usually used for primary closure (Fig. 6). After that, a white gauze is used to inspect bile leak.

Fig. 6
A photograph of primary closure of common bile duct through suture.

Primary closure of CBD

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T-tube placement: A suitable T-tube size is selected according to the size of the CBD. Suturing in a continuous or interrupted fashion with absorbable 3.0 or 4.0 suture is performed around the T-tube (Fig. 7). Flushing water through T-tube helps detect a leak that needs to be reinforced.

Fig. 7
Two photographs of the process of closure of common bile duct by use of suture.

Closure of CBD around T-tube

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Drainage and Closure of Trocar Sites

A subhepatic drain is routinely placed and usually removed after 2–3 days if there is no bile leak.

All trocar sites are closed.

Complications and Management

Bile leak rate was reported around 5–7% [2]. Bile leak is usually mild and self-limited.

Complications specific to primary closure are persistent cholangitis or biliary obstruction. This happens when there are retained stones or distal obstruction of the CBD or ascending acute cholangitis.

Late stricture of CBD may occur and less than 1%, mostly because of inappropriate closure technique or choledochotomy in a CBD less than 7 mm.

Summary

Laparoscopic choledochotomy is feasible and safe. Complication rate is low. Complications are usually mild and self-limited. Appropriate indication of laparoscopic choledochotomy is important.