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 Table of Contents  
Year : 2022  |  Volume : 28  |  Issue : 2  |  Page : 113-118

Laparoscopic common bile duct exploration: A single-centre experience

Department of Surgery, GEM Hospital and Research Centre, Thrissur, Kerala, India

Date of Submission23-Oct-2022
Date of Decision10-Dec-2022
Date of Acceptance12-Dec-2022
Date of Web Publication30-Jan-2023

Correspondence Address:
Dr. Arjun Balram
GEM Hospital and Research Centre, Thrissur - 680 005, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ksj.ksj_34_22

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Background: Laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy (LC) is as effective as two-stage endolaparoscopic treatment but with a shorter hospital stay, lower cost and lower recurrent stone rate. Aim: The aim of this article was to report the authors' experience with LCBDE with a rigid telescope during LC. Methods: A retrospective analysis of patients who underwent LCBDE for ductal stones in a single surgical unit were studied from 2017 to 2021. Results: A total of 55 LCBDEs were performed during this period. Ninety percentage of patients presented with biliary colic. Of these 18% were following endoscopic retrograde cholangiopancreatography failure. About 50.4% of patients had multiple stones. About 16.8% of patients had undilated CBD. The mean operative time was 178 ± 71.62 (80–300). The conversion rate was 1.8%. All patients underwent CBD exploration through a supraduodenal choledochotomy. In 9% of cases, pneumatic lithotripsy was used because of impacted large stones. The closure was done over T-tube in 58.18% of cases and over antegrade endobiliary stent in 41% of cases. Post-operative complication was minor CD 1 and 2. The overall success rate of LCBDE was 98%. Conclusion: LCBDE should be considered for treatment for patients with gallstones with CBD stones, especially for patients with large and multiple stones.

Keywords: Common bile duct exploration, cholecystectomy, choledochotomy, gallstones, laparoscopy, t-tube

How to cite this article:
Balram A, Harsha M, Tadikamalla V, Nair SP, Varghese C J. Laparoscopic common bile duct exploration: A single-centre experience. Kerala Surg J 2022;28:113-8

How to cite this URL:
Balram A, Harsha M, Tadikamalla V, Nair SP, Varghese C J. Laparoscopic common bile duct exploration: A single-centre experience. Kerala Surg J [serial online] 2022 [cited 2023 Mar 25];28:113-8. Available from: http://www.keralasurgj.com/text.asp?2022/28/2/113/368591

  Introduction Top

Laparoscopic cholecystectomy (LC) is the standard treatment for patients with symptomatic gallstones.[1],[2] Common bile duct (CBD) stones are detected in 11%–25% of patients with gallbladder stones[3] and about 10% of patients who undergo cholecystectomy for symptomatic cholelithiasis have CBD stones, including silent stones.[4],[5],[6] The European Association for Endoscopic Surgery (E.A.E.S.) recommends all patients with symptomatic gallstones should be assessed for the presence of CBD stones and treated based on the patient's risk classification as defined by the American Society of Anesthesiologists.[7] However, the most appropriate management of CBD stones is still debated.

Previously open choledocholithotomy with cholecystectomy was the only option available in the management of CBD stones. Nowadays, the most commonly followed option is the two-stage procedure through endoscopic retrograde cholangiopancreatography (ERCP), followed by LC. In some situations, it is done after LC. Laparoscopic CBD exploration (LCBDE) and stone removal during LC were introduced more than 20 years ago. However, it is considered a treatment option in a limited number of patients. A recent Cochrane review concluded that there were no significant differences in morbidity, mortality and failure rates between single-stage LCBDE and the two-stage endoscopic approach. In a clinical trial set up by the E.A.E.S., one-stage LCBDE and stone removal during LC have proven to be equivalent to the two-stage approach, but with a shorter hospital stay.[8],[9] This finding was confirmed in a recent meta-analysis.[10],[11]

One-stage LC-LCBDE can be performed by a transcystic or a direct choledochotomy approach. The two techniques, however, are not equivalent, but have different indications and require different levels of expertise. Only a few patients may be suitable for the transcystic approach, whereas laparoscopic choledochotomy approach can be done in most of the patients.

Laparoscopic choledochotomy approach is done usually with a flexible choledochoscope. It can also be performed with a rigid telescope. The aim of this article was to report our experience with one-stage LCBDE using a rigid telescope focusing on the selection of cases, operative technique and outcome.

  Materials and Methods Top

A retrospective analysis of prospectively collected data of patients who underwent LCBDE from 2017 to 2021 was performed. Pre-operative investigations included liver function tests, abdominal ultrasonography, magnetic resonance cholangiopancreatography (MRCP) and computed tomography scans in selected patients. MRCP was done in the majority of patients. Intraoperatively extraction method of CBD stones, CBD closure over antegrade stenting or over “T”-tube was looked into. Advantages and limitations of rigid scope were analysed.

5 trocar approach was opted for LC with CBD exploration [Figure 1]. 4 trocars were used as in the standard LC and 5th 5 mm trocar between umbilical and epigastric 10-mm ports. This port was used for retraction of the duodenum, and the same incision was used for the introduction of the rigid scope to visualise the proximal bile ducts through the choledochotomy. 30° 10 mm telescope was used for laparoscopy, and initial dissection was done at Calot's triangle to dissect the cystic duct. The cystic artery was divided.
Figure 1: Port positions

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The cystic duct was delineated and clipped towards the gallbladder to prevent the slipping of stones from the gallbladder to CBD during the procedure. The next step was the choledochotomy to a size of 10 mm with needle cautery [Figure 2]. The site for choledochotomy was selected at the distal bile duct either at the junction of the cystic duct to CBD or proximal to the crossing of the duodenum. In cases where possibilities of choledochoduodenostomy are anticipated, the incision on CBD was placed accordingly.
Figure 2: Choledochotomy

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The extra 5-mm port was removed and 5-mm rigid telescope with working channel (nephoscope) with an attached separate camera and monitor was introduced through the 5-mm incision and through choledochotomy for visualisation of the proximal bile duct and hepatic ducts. Saline irrigation was done for visualisation. Any stones encountered were removed. Removal of stones was done by irrigation of saline through the rigid scope which helps to flush out the stones through the choledochotomy. If not successful, stones are removed by Dormia basket and passed through the working channel of the scope [Figure 3]. The impacted big stones were crushed under vision with pneumatic lithotripter passed through the scope [Figure 4]. The crushed stones are removed by the same methods described.
Figure 3: Stone removed by Dormia Basket

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Figure 4: Crushing of stones with lithotripter

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The rigid scope was removed and the 5-mm port was reintroduced. A separate 5-mm incision was made high up in the subcostal area towards the epigastrium between 10 mm and 5 mm, and through this incision, the rigid scope was passed and through the choledochotomy, distal CBD was visualised [Figure 5]. The stones seen were removed by the measures described. After complete clearance, the scope could visualise the CBD up to the ampulla [Figure 6]. Operative cholangiogram was not usually necessary.
Figure 5: Lower CBD after stone removal. CBD: Common bile duct

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Figure 6: Visualisation of ampulla

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Decision was taken whether to opt for antegrade CBD stenting or “T”-tube placement. If opening at the ampulla was seen well then stenting through the scope over the guide wire was done. 7F double pigtail plastic stent was used [Figure 7]. The scope was removed, the proximal curved part of the stent was cut partly, and the remaining part of the stent were introduced into the CBD.
Figure 7: Endobiliary stenting

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The choledochotomy was closed with absorbable continuous stitches. If the ampulla opening was not seen well or there was difficulty in passing the guide wire, closure of CBD was done over T-tube. The LC was completed. The gallbladder and stones were placed in a endobag and removed. The spilled-over saline was sucked out from all quadrants of the abdomen. The drain was kept in the subhepatic area through the lateral port. The “T”-tube was brought out through the subcostal port and a leak test was done. The T-tube was clamped, the drain was removed, and the patient was discharged home. T-tube was removed later on follow-up.

The patients were reviewed 10 days and 3 weeks after surgery. Clinical examination, LFT and USG abdomen were done. Further follow-up was done based on initial results or in routine cases after 1, 3 and 6 months.

Descriptive and inferential statistical analyses were carried out. Results on continuous measurements were presented on mean ± standard deviation (min–max) and results on categorical measurements were presented in numbers (%). The following assumptions on data were made: dependent variables should be normally distributed, samples drawn from the population should be random and cases of the samples should be independent.[12],[13],[14] Statistical software SPSS 22.0 (IBM, India) and R environment ver. 3.2.2 (IBM, India) were used for the analysis of the data, and Microsoft Word and Excel were used to generate graphs and Tables.

  Results Top

From 2017 to 2021, 55 patients underwent laparoscopic CBDE. Pre-operative patients' data for each group are reported in [Table 1].
Table 1: Pre-operative patient data

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There were 35 females and 20 males in the study group. The mean age and range were 58.07 (20–83) years. Ninety percentage of patients presented with biliary colic. In nine cases, CBD was undilated. Multiple stones were present in around 30 (54.54%). The diameter of the CBD ranged from 5.6 to 20 mm. Five patients had previous abdominal surgery. Ten patients had failed ERCP and five patients were in cholangitis. The mean operative time was 178 ± 71.62 (80–300). Multiple methods were used for stone extraction, mostly done with irrigation and flushing and with Dormia baskets and with lithotripter if required. Ninety percentage of cases had multiple stones and were distal to choledochotomy. In 32 cases (58.1%), choledochotomy was closed over T-tube and the rest over a stent [Table 2].
Table 2: Intraoperative results

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All patients were given post-operative broad-spectrum antibiotics for 1 week. Most post-operative complications were minor and Clavien–Dindo's classification Grade 1 and 2. Hospital stay was around 7 ± 2.75 (3–15 days). Increased hospital stay was for cases where choledochoduodenostomy was done as an additional procedure. Recurrent stone was seen in one patient, who presented within 3 months, was managed with ERCP and stone removal [Table 3].
Table 3: Post-operative complication

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  Discussion Top

CBD stones are seen in 10%–15% of patients with symptomatic gallbladder stones.[4],[6],[15] The popular options for CBD stone removal are endoscopic retrograde cholangiography, CBD stone clearance followed by LC. Even though LC is the gold standard for the treatment of symptomatic gall stones, LCBDE as an option of CBD stone removal is not well accepted.[1],[16] One of the reasons is that a flexible choledochoscope is used for CBD stone clearance. When flexible scope is used, surgeons need to have additional endoscopic skills than laparoscopy skills. There is a learning curve associated with this procedure. Moreover, the scope is expensive and it can get easily damaged.[17],[18],[19] The channel size is less. Hence, the clearance of the bigger stones can be difficult. The rigid scope gives a very good vision, and the channel size is big. The rigid scope enables the removal of big stones as well as multiple stones successfully. CBD exploration using a rigid scope is technically comfortable in dilated CBD. A 5-mm rigid scope with the working channel is used if the CBD diameter is >7–8 mm. If not dilated, the thin rigid scope is used for CBD exploration. Unlike the two-stage procedure, ERC and CBD stones removal followed by LC the single-stage procedure, LCBDE and LC carries less morbidity and hospital stay.[10],[20],[21],[22],[23] The equipment cost for LCBE with a rigid scope is much less compared to that of ERCP or flexible choledochoscope. Hence, the single-stage LCBDE with LC likely to be less expensive. Big stones and multiple stones can be very well removed by big rigid scopes successfully. Occasionally, when there is any doubt about complete clearance or in cases of distal strictures of CBD, the surgery was completed with choledochoduodenostomy.[24],[25],[26]

There are limitations of rigid scope.[17],[19] The procedure becomes uncomfortable in CBD without dilatation or with minimal dilatation. Thin rigid scopes can be used in these situations, but it will be technically difficult. There can be problems in thin CBD. The rigid scope can tear CBD if excessive force is used during CBD exploration. However, usually, CBD will not be thin when CBD stones are present. There would not be much difficulty during the visualisation of the proximal biliary system. The angulation is much less when the scope is passed from below into the bile duct. The angulation was more when the scope is passed from above to visualise the distal bile ducts. Here, the scope can tear the bile duct if too much pressure is created on the bile duct. Hence, the skin incision for rigid scope is placed as high as possible and the choledochotomy is placed as low as possible proximal to the crossing of the duodenum. If required, the pneumoperitoneum pressure is also reduced to facilitate a smooth passage of the rigid telescope to the distal bile duct. The successful laparoscopic management of CBDS is dependent on several factors including surgical expertise, adequate equipment, the biliary anatomy, CBD diameter and the number and size of CBD stones.[27],[28],[29] Successful stone clearance rates for LCBDE range from 85% to 95% with a morbidity rate of 4%–16% and mortality of 0%–2%.[30],[31],[32],[33] Complications include bile leak and CBD stricture.

Meta-analysis showed no statistically significant difference in any of the outcomes between T-tube and primary closure of choledochotomy. The hospital stay which was significantly lower in the primary closure group.[34],[35] An alternative to T-tube is antegrade stent placement or primary closure.[36] We have done closure of CBD with either T-tube or antegrade stenting. Our CBD stone clearance success rate is 98% with morbidity of 1.8% and mortality of 0%. This is comparable to the data seen in the meta-analysis. Patients who underwent closure over stent were discharged earlier than patients with T-tube. The T-tube was closed before discharge and was removed later on follow-up after a T-tube cholangiogram. In cases of antegrade stenting, the presence of the stent is checked by X-ray imaging. If the stent remains, it was removed by endoscopy. In the majority of patients, the stent would have passed out and there was no need to intervene. This was because the part of the proximal pigtail was removed. However, the stent remains in the initial period of healing of choledochotomy closure.

Single-stage LCBDE with LC has more advantages compared to its limitations. Our experience with single-stage procedures with rigid telescope is with a high success rate and low incidence of complications

  Conclusion Top

Laparoscopic CBD stone removal along with LC is a very successful option in the management of choledocholithiasis. It is a single-stage cost-effective procedure with less morbidity, complications and shorter hospital stay. The learning curve is also shorter. However, decisions of laparoscopic rigid scope CBD clearance versus endoscopic retrograde CBD stone removal should be taken based on patient condition, skill available, CBD diameter, number of stones and size of stones. The laparoscopic rigid scope CBD and stone removal can be done in many more cases than that are being done today.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

  [Table 1], [Table 2], [Table 3]


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