Multiple Instrument Guide and 2.8 mm Choledochoscope for LCBDE

Donald E Wenner, MD. Roswell Regional Hospital

Introduction: The multiple instrument guide (MIG) was created for laparoscopic surgeons to achieve a practical, safe, organized and efficient LCBDE procedure. The MIG is designed to be used in conjunction with the 2.8 mm choledochoscope. It is useful in both the trans-cystic duct and the choledochotomy approaches to LCBDE. The MIG is used through a standard 10mm laparoscopic port. The goal of this study is to achieve a totally laparoscopic approach to CBD stone disease and to develop procedural methodologies based on commonalities in clinical presentation, anatomy, stone size, location, and number.

Methods: A database was maintained after each use of the MIG. Choledocholithiasis was confirmed with dynamic fluoroscopic intra-operative cholangiography in every case. Clinical demographics, pre and post operative laboratory findings, operative time, stone size, number, location, success at stone clearance, operative approach (i.e. trans-cystic duct or choledochotomy), tool combinations, use of drains, t-tubes, choledochotomy repair, etc were all recorded concurrently with the procedure. Post-operative complications were monitored and recorded.

Results: The MIG in conjunction with the 2.8mm flexible video choledochoscope was used on 151 LCBDE procedures. Stone size > 8mm correlated with need for a choledochotomy LCBDE procedure. This was required in 31 % of cases and took a mean of 143 minutes. Trans-cystic duct LCBDE was used in 65% of cases, with a mean operative time of 122 minutes. Conversion to an open LCBDE procedure was required in only 4% cases. Successful stone clearance was achieved in 97% of these cases overall. There has been a shift in procedural methodology as the learning curve for the MIG instrument progressed, as evidenced by development of an efficient procedural algorithm based on stone and bile duct characteristics. The LCBDE procedure using this methodology has not resulted in any cases of clinical pancreatitis. T-tubes were used early in the series, but their use was associated with complications principally dislodgement and bile leakage and there use has been abandoned in favor of choledochotomy closure.

Discussion: There is the potential that LCBDE using the MIG and 2.8 mm choledochoscope may be superior to ERCP techniques, as pancreatitis was not seen in this fairly sizable series. This complication can be devastating in the unfortunate patient that experiences a severe case of pancreatitis. A randomized controlled study is needed. Challenges to more widespread use of LCBDE are several; among them is lack of surgical training in LCBDE. In many teaching hospitals, patients with clinical or laboratory signs of choledocholithiasis are admitted to the GI service and taken for ERCP prior to cholecystectomy. Many surgeons do not perform routine cholangiography and the diagnosis is missed or delayed. Further, government price control over surgical procedure reimbursement does not reward surgeons for the added surgical time, expertise and effort required. Surgeons are reluctant to embrace a new procedure without specific training in our onerous malpractice environment. Training in LCBDE is difficult as the cases present in an unpredictable and urgent fashion. Training models are basic at best and animal models for choledocholithiasis are not available.