OBJECTIVES: Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy (LC). The probability that a patient has CBD stones is a key factor in determining treatment strategies. Clinical models are inaccurate in predicting common bile duct (CBD) stones for patients who will undergo cholecystectomy for lithiasis. Prior to the development of LC, the management of these patients included CBD exploration at the time of cholecystectomy. In the era of LC, because of an obvious lack of expertise in laparoscopic surgery, if the diagnosis of choledocholithiasis was established during intraoperative cholangiography, the surgeon was confronted with a therapeutic dilemma-that was, the choice between conversion to open surgery, or postoperative ERCP (two-stage treatment). Surgeons elected to detect and treat preoperatively CBD stones by endoscopic sphincterotomy (ES) since they considered laparoscopic common bile duct exploration (LCBDE) as an unduly, complex, and demanding procedure. With increasing experience of laparoscopic surgeons, it seemed logical to develop a mini-invasive one-stage procedure using the laparoscopic approach. We have opted to treat patients with choledocholithiasis in only one session during the LC.
METHODS: This study evaluates our results of LCBDE in a series of 540 patients treated over 36 months. The purpose of this study is to evaluate the feasibility and safety of a single-stage management of CBD stone during LC. The inclusion criterion was the presence of ultrasound proven gallstones. Patients were excluded from the study if there was evidence of carcinoma of the gallbladder.
RESULTS: Common bile duct stones were demonstrated in 68 patients by routine intraoperative cholangiography. For 7 patients, ES was performed, with successful stone clearance after completion of LC. LCBDE was done in 61 patients; all LCBDEs were completed laparoscopically. In 21 patients, CBD closed on a C-Tube and in 10 patients LCBDE completed with T-tube insertion. In 6 cases no CBD drainage was performed. In 60 cases flexible choledochoscopy was done. Choledochoduodenostomy was done in 24 cases. The mean operative time was 90-130 minutes (mean 95), which is significantly greater than conventional laparoscopic standard cholecystectomy (range 20-40 minutes, mean 30). LCBDE was performed without immediate or late complications. CONCLUSION: There are no debates in the detection and the management of CBD stones in the era of LC. LCBDE is a cost-effective, efficient, and minimally invasive method of treating choledocholithiasis. As clinical models are inaccurate in predicting CBD stones, routine use of IOC during LC is necessary.
RECOMMENDATION: We believe that for surgeons familiar with open common bile duct exploration and laparoscopic cholecystectomy, the next logical step is laparoscopic exploration of the common bile duct at the time of cholecystectomy, which is safe and readily mastered. It is hoped that LCBDE will be adopted so patients can undergo a single procedure to remove their gallstones and common bile duct stones if they exist and to decrease the incidence of normal preoperative ERCPs, the complications related to ERCP, and the need for a second procedure postoperatively to clear stones if they are found.
Program Number: P385