Limitations of the One Step Laparoscopic Cholecystectomy

Corey Richardson, MD, Maris Jones, MD, Matthew Johnson, MD, Charles St Hill, MD, Louise Shadwick, RN, Nathan Ozobia, MD, FACS

University of Nevada School of Medicine and University Medical Center of Southern Nevada

Introduction: The first One-Step procedure (laparoscopic cholecystectomy, intraoperative cholangiogram (IOC), and if indicated, intraoperative endoscopic retrograde cholangiopancreatography (ERCP)) was performed at University Medical Center, Las Vegas, NV in 1997 by Nathan Ozobia, MD. The experience was presented at the 6th World Congress of Endoscopic Surgery in Rome, Italy in 1998. In 2010, two surgery residents at UNSOM began training in diagnostic and therapeutic ERCP and a formal One-Step program was initiated, leading to numerous institutional review board studies and new innovative techniques of treating obstructive complications of biliary disease.

Materials & Methods: A retrospective analysis (1997-2011) was completed and a prospective analysis is underway regarding utilization of the One-Step procedure. Over 120 cases have been reviewed thus far and the difficulties and limitations encountered include:

• Availability of a surgical attending with privileges in advanced ERCP to be present during procedures.
• Multiple large common bile duct (CBD) stones can be treated by a variety of methods, including multiple balloon sweeps, mechanical lithotripsy, basket extraction, balloon dilatation of the ampulla, and biliary stenting.
• Giant CBD stones >1.5 cm.
• Soft giant stones are serially crushed, but these patients invariably are stented and later brought back for potential laser fragmentation and basket extractions.
• A few cases of poorly performed IOCs have resulted in gas bubbles appearing to be CBD filling defects, leading to negative ERCPs.
• Adequate intra- and extra-hepatic filling of the biliary tree, good drainage films, and proper dye concentration when performing ERCPs are essential in limiting unnecessary papillotomies and their potential complications.
• Duodenal pool, gravitation of duodenal contents to the medial wall obscuring the view of the ampulla, is a problem specific to the One-Step procedure given that all patients undergo ERCP exclusively in the supine position.
• Patients with Mirizzi Syndrome have an increased potential for bile duct injury and early consideration should be given to an open cholecystectomy. However, the supine ERCP is still completed, if indicated, following the cholecystectomy.
• Patients with Peri-Vaterian Diverticulum should be placed in the prone position if early attempts at cannulation are unsuccessful in the supine position, as the ampulla is best seen and accessed in the prone position.

Results: The experience gained in the One-Step procedure has led to numerous changes in our practice. ERCPs are always done after the cholecystectomy to avert the impaired visibility caused by gaseous distension of the duodenum, stomach, and hepatic flexure that occurs after ERCP. We no longer take exhaustive measures to clear the CBD in cases of innumerable and large stones. Instead, we use stents liberally and return to the OR days or weeks later, which has kept our operating room times, complications, and radiation exposure at acceptable levels. Also, meticulous attention to technique during IOCs and ERCPs can avoid unnecessary ERCPs and papillotomies, respectively.

Conclusion: The One-Step procedure is an evolving concept and larger volumes are needed to establish its place in general surgery. As more surgical endoscopists utilize this procedure, training can be made available to residents if approved by the surgical board.

Session: Poster Presentation

Program Number: P326