Incidence of Unsuspected Stones in the Common Bile Duct During Elective Laparoscopic Cholecystectomy: A Word of Caution

Gintaras Antanavicius, MD FACS, Rodolfo H Scaravonati, MD, Carlos A Cutini Cingozoglu, MD, Patricio E Donnelly, MD, Mariano Irigoyen, MD, Rodrigo Moran Azzi, MD, Victor H Serafini, MD FACS. Sanatorio Guemes; Abington Health

 Introduction: the incidence of unsuspected stones in the common bile duct (CBD) is about 5%. When  a stone in the CBD during elective cholecystectomy is found fortuitously,  the appropriate strategy to carry out is still uncertain. The risk of a potentially life-threatening complication, justified systematic extraction of all stones in the CBD, whether symptomatic or not. With adapted equipment and a well trained surgeon, this can be done during the same operation.
We have analyzed a group of patients, who underwent elective laparoscopic cholecystectomy, without preoperative suspicion of ductal stone to determinate the incidence and morbility in a University Hospital.

Methods: Retrospective analysis from a prospectively collected database.
Inclusion Criteria: Elective laparoscopic cholecystectomy with intraoperative CBD stone found during transcystic cholangiography.

Result: Between March 2008 and August 2011, a total of 2471 laparoscopic cholecystectomy operations were perfomed. Of these,1453 were elective procedures. Unsuspected lithiasis in the CBD were diagnosed in 3.16% patients (n=44) during the intraoperative cholangiography (34 females, 10 males). All cases were initially treated by transcystic exploration. The rate of conversion was 2.5% (n=2), 9% required choledochotomy and closure on a T – Tube (n=4). In one case primary closure was performed. The average post operative stay was 1.4 days (range 1-10 days). None of the patients required post operative ERCP (Endoscopic Retrograde Cholangiopancreatography) neither second procedure. The morbidity was 6.8% (n=3) and there was no mortality.

Conclusion: Our incidence of unsuspected CBD stone was similar to global rates (3.16%). Most of the cases (80%) were resolved it successfully by transcystic exploration without biliary duct injury, and in the remainder, CBD was clear with a choledochotomy in the same procedure. We conclude that systematic transcystic exploration should be done in every procedure, even in patients without preoperative suspicion of ductal stone.

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