Laparoscopic Management of Cbd Stones: An Indian Experience

India has a high incidence of gall stones and consequently of CBD stones (CBDS) which are very different from that seen in the west. It is not infrequent to see multiple, large, impacted stones in a hugely dilated CBD. Therefore many of these patients have been managed by open CBD exploration, even after advent of laparoscopic cholecystectomy (LC), since these large stones pose significant challenges for extraction by ERCP. This series presents the largest experience of managing CBDS using a laparoscopic approach from the Indian subcontinent.

Material and Methods
Over the last 7 years, 150 patients of documented CBDS were treated laparoscopically in a single surgical unit at a tertiary care hospital in New Delhi. Of these 4 patients were managed through transcystic route and 140 through the trans-choledochal route. Of the latter, 29 patients were managed with a T-tube, 60 patients with an endobiliary stent, 31 patients had a primary closure of CBD, and 20 had a choledochoduodenostomy. There were 6 conversions to open procedures.

There were 34 male and 116 female patients with age ranging from 15 to 72 years (mean of 46.9±12.4 years). The mean size of the CBD on ultrasound was 11.7±3.7mm (range of 4.0mm to 23.0mm) while that on MRCP was 13.8±4.7mm (range of 4.1mm to 30.0mm). The average number of stones extracted per patient was 7.5±11.8 with a range of 1 to 70. The size of the extracted stones varied from 2mm to 30mm, with the average stone size being 11.5±4.8mm.The average duration of surgery was 139.9±26.3 min with a range of 90 to 205 min. The maximum duration was seen with conversion to open procedures followed by those with T-tube drainage. The mean intra-operative blood loss was 103.4±85.9 ml (range 10 to 500 ml).
In patients with T-tube drainage, the average duration for which the T-tube was kept was 13.1±5.0 days (range 9 to 36 days). There was one post-operative death (0.7%). Twenty three patients (15%) had nonfatal postoperative complications (25 events in total) ranging from minor complications like wound infection to more serious ones like bile leakage. There were 3 cases of retained stones (2%), all of which were managed effectively with post-operative ERCP.Post-operative stay ranged from 2 to 33 days with an average of 4.6±4.1 days. The patients with conversion to open procedures had the longest stays, while those with primary closure had the shortest stays. 96% of the procedures could thus be completed by laparoscopic techniques.

This study shows that for the subgroup of patients with multiple, large, impacted stones in a dilated CBD who were traditionally subjected to open CBD exploration owing to inefficiency of ERCP, minimally invasive procedure with its attendant benefits, in the form of laparoscopic CBD exploration (LCBDE) is highly effective and safe procedure. LCBDE when performed by an experienced surgeon results in no additional morbidity or mortality as compared to open surgery, with excellent success rates and 98% stone clearance from the CBD.

Session: Podium Presentation

Program Number: S018

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