Anubhav Vindal, MS, MRCSEd, FAIS, FCLS1, Pawanindra Lal, MSFRCSEd, FRCSGlasg, FRCSEngFACS1, Jagdish Chander, MS, FCLS2. 1Division of Minimal Access Surgery, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi., 2Department of Surgical Sciences, Jaypee Hospital, NOIDA, UP
Characteristics of common bile duct stones (CBDS) seen in the Asian population are very different from those seen in the west. The stones are very frequently multiple, large in size, and impacted and the CBD is often hugely dilated. It is because of these reasons that extraction of these stones by the endoscopic modalities poses considerable challenge. We present our experience of laparoscopic CBD exploration over a 12 year period, which is the largest single centre experience from South East Asia.
Over a 12 year period between 2003 and 2014, 250 patients with documented CBDS were treated laparoscopically using the trans-choledochal approach at a tertiary care teaching hospital in New Delhi. All the patients with gallstones presenting to surgical out patient department underwent basic investigations to screen them for CBDS, which was then confirmed on magnetic resonance cholangio pancreatography (MRCP). All the patients were operated through the standard 5 port technique described previously by the authors. A transcholedochal approach was utilized in all the patients. Intraoperative choledochoscopy was performed in all patients using a rigid 8/10F ureteroscope, to visualize and remove the CBDS and to check for the completion of removal at the end of the procedure. The calculi were extracted under direct vision using various techniques like Dormia basket, fragmentation using intra-corporeal Holmium laser lithotripsy and flushing the fragments into duodenum. The CBD was closed with or without drainage according to the merits of each case.
There were 47 males and 203 females with age ranging from 18 to 70 years. The mean size of the CBD on ultrasound was 11.7 ± 3.7 mm and on MRCP 13.8 ± 4.7 mm. The number of stones extracted varied from 1 to 70 and the size of the extracted stones from 5 to 30 mm. The average duration of surgery was 144.9 ± 22.3 min (range 90 – 220 min) and the mean intraoperative blood loss was 113.4 ± 75.6 ml. There were 7 conversions to open procedures. Rigid choledochoscopy was used in all the patients and complete clearance of CBD was achieved in nearly all the patients (98.4%). The CBD was closed over a T tube in 36 patients (14.8%), over an endobiliary stent (10F) in 102 patients (41.9%) and primarily without any drainage in 76 patients (31.2%). Twenty nine patients (11.9%) underwent a choledochoduodenostomy due to a grossly dilated CBD with or without impacted CBDS. Twenty patients (8%) had nonfatal postoperative complications and there was one postoperative mortality (0.4%). Four patients had retained stone (1.6%) and one patient developed a recurrent stone (0.4%). All were managed effectively with endoscopic means. The mean post-operative hospital stay was 4.1 days (range 2 to 33 days).
The authors believe that the use of a rigid ureteroscope for choledochoscopy in laparoscopic CBD exploration (LCBDE) provides a near 100% stone clearance rate even in patients with large and impacted CBD stones.