Debate continues regarding the optimal algorithm for the management of bile duct stones. Several facts are commonly agreed upon

• Approximately 10% of patients treated for gallstones will be found to have bile duct (BD) stones at some time during treatment.
• Symptomatic BD stones, although not common, can result inbiliary obstruction, cholangitis or pancreatitis.
• In the laparoscopic era, BD stones are most frequently handled endoscopically by ERCP, pre- or post-operatively.
• Although safe, complications from ERCP are seen in approximately 10% of procedures.
• 40% to 60% of ERCP examinations for suspected BD stones will be negative.

In caring for patients with gallstones many, but not all, bile duct stones may be anticipated prior to laparoscopic cholecystectomy. This is most reliably identified by a combination of CBD diameter on preoperative studies and blood chemistries. If there is a reasonable likelihood that choledocholithiasis may present, a decision must be made whether to address the stones prior to cholecystectomy.

Many surgeons prefer to have the bile duct addressed prior to visiting the operating room when BD stones might be present. Pre-op ERCP can streamline the cholecystectomy and addresses concerns regarding a possible return to the operating room if post-operative ERCP was unsuccessful in removing BD stones. As identified above, pre-operative ERCP carries additional risks, costs, anesthetics, and up to 50% of these proceudres will be negative or non-therapeutic. As the GI community becomes even more facile in their ability to clear the bile ducts postoperatively (which they are), concern over stones left behind in the operating room following laparoscopic cholecystectomy lessen. This should make surgeons more confident in taking patients to the operating room with suspected BD stones and should be within all surgeons’ reach.

The Cochrane Collaboration Review in 2006, “In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones. The use of ERCP necessitates increased number of procedures per patient.” …” with no significant difference in morbidity and mortality.”

Removing stones via the cystic duct is an elegant procedure. The technical skills required to perform each individual step in the procedure 83 are possessed by virtually all general surgeons. The ability to complete a laparoscopic cholecystectomy with cholangiogram, start a central venous line and operate a flexible endoscope are the prerequisite skills which are required and possessed by most. All that remains is putting these elements together in order with few additional items found outside a typical operating supply room. A standard program for performing this procedure is available for hands on training at the “Learning Center” at this meeting. it will be included the “Top 21” video collection from SAGES will have an excellent demonstration of these procedures.

After minimally invasive access to the abdominal cavity is achieved, laparoscopic ports are placed in a standard fashion for laparoscopic cholecystectomy. Following dissection of the gallbladder neck and identification of the cystic duct, a surgical clip is placed on the cystic duct at the level of the gallbladder. A small cystic duct incision is fashioned just below the clip and its lumen is identified. A 5 Fr. cholangiogram catheter is inserted percutaneously in a location that will facilitate further access to the cystic duct and common bile duct if necessary. Most commonly the catheter will be postioned close to the costal margin, between the mid epigastric and lateral ports. Once in the abdomen, the catheter is flushed with saline to clear it of air. A dissector is used to advance the catheter into the ductotomy and is then secured with a non-occlusive surgical clip. Contrast is then injected through the catheter under fluoroscopy. This allows rapid identification of biliary ductal anatomy, filling defects within the bile ducts, and flow of contrast into the duodenum. In very dilated ducts, the contrast should be diluted to one half strength to avoid camouflaging smaller stones with the radioopaque contrast. Many surgeons are becoming facile in laparoscopic ultrasound of the common bile duct. This allows a non-invasive cholangiogram without radiation. In many hands, it is also quicker than traditional cholangiography. Though it is important to confirm the absence of stones with a cholangiogram while climbing the learning curve, ultrasound allows visualization of the duct without an incision in the duct.- A normal cholangiogram will demonstrate the entire bile duct without filling defects. Unobstructed flow should be demonstrated into the duodenum, through the cystic duct/ common bile duct junction, and through the bifurcation of the hepatic duct with filling of the intrahepatic biliary radicals. If a normal cholangiogram is observed, the catheter can be removed, the cystic duct may be ligated, and the gallbladder removed in the usual fashion. In this first and most common situation, the ERCP has been eliminated. If stones are found in the common bile duct or hepatic ducts, a decision can then be made on how to proceed. For common bile duct stones less than 3 to 4 mm in diameter an attempt should be made to mechanically flush the stones from the duct. Intravenous administration of 1.0 mg of glucagon by anesthesia can help relax the sphincter of Oddi and facilitate passage of small stones. Four minutes following glucagon administration, the cystic duct catheter is flushed with several 10cc syringes of saline. This procedure will clear the duct in many cases. A repeat cholangiogram should then be performed. If the duct is clear, the cholecystectomy can then be completed in the usual fashion. In this second and also common situation, the ERCP has been avoided. If small gallstones, 3mm or less, remain in the duct, observation should be considered, as a majority of small stones will pass spontaneously. For common bile duct stones that are too large to be cleared by simple flushing, many surgeons are successful in removing these stones utilizing a Fogarty balloon catheter. Using graspers, a 4-Fr. Fogarty is inserted transcystically into the common bile duct past the stones. The balloon is then inflated and the catheter is slowly withdrawn from the cystic duct using graspers. In many cases, the Fogarty will carry the stones out of the cystic duct and into the abdomen. Following a repeat cholangiogram, the gallbladder can be removed and any free stones can then be retrieved later with the gallbladder. Alternatively, a stone retrieval basket may be inserted through the cholangiogram catheter into the common bile duct. The basket is then opened under fluoroscopic guidance past the stone. The basket is then slowly withdrawn and closed. When the basket is unable to fully close and the stone is captured, the entire assembly is withdrawn from the cystic duct and the stone is removed into the abdomen.

Laparoscopic choloedochoscopy and stone removal has been shown to be effective for the removal of bile duct stones in the majority of cases. Prior to undertaking laparoscopic common bile duct exploration, the appropriate equipment must be gathered. Disposable equipment is available from several manufacturers as kits and/ or individual parts. Utilizing a laparoscopic choledochoscope or ureteroscope, with a 1.2mm working channel, allows removal of stones under direct vision. Following cholangiography, a 0.035-inch flexible tip guide wire is inserted through the catheter. The catheter which must be 5 french or greater in diameter to allow the wire to pass. In many cases, the guide wire will pass through the common bile duct into the duodenum, which can be confirmed by fluoroscopy. The catheter is then removed, in a Seldinger fashion, leaving the guide wire in place. With the guide wire in place, a plastic sheath approximately 12 french in diameter is placed over the wire through the abdominal wall. This allows safe passage of the choledochoscope and other equipment into the abdomen without injuring the scope’s optic fibers. Alternatively, a 3 mm inner cannula, of the type commonly used to pass an endoscopic ligation loop, can be used through a standard laparoscopic port to pass the choledochoscope. The cannula will prevent injury of the scope by the port’s valve and may be less expensive than other sheaths. Dilating the cystic duct with an angioplasty balloon can facilitate retrieval of stones and passage of the choledochoscope through the cystic duct. A 8mm angioplasty balloon catheter is placed over the guide wire into the cystic duct. The balloon is then inflated to 6 atmospheres of pressure for 5 minutes. The balloon is then deflated and the catheter removed, again leaving the wire in place. As an alternative to angioplasty balloons, which can be costly, progressive urethral dilators may also be used for this purpose. A 3 mm choledochoscope or ureteroscope can then be introduced over the guide wire through the protective sheath into the abdomen. Once visualized in the abdomen, the scope can be advanced into the cystic duct using graspers, which are padded to protect the flexible scope. A separate camera, light source and monitor are then used to observe the interior of the ducts. Alternatively, a video mixer may be utilized which displays both the choledochoscope and laparoscope pictures on the same monitor screen. This can reduce the amount of equipment in the operating room at one time. Adequate visualization of the duct interior requires that pressurized saline is connected to a working side port of the choledochoscope. A watertight valve is needed on the end of the working port to prevent the spray of saline while guide wires and baskets are used in the scope. Once a stone is encountered, the guide wire is removed and a wire retrieval basket is inserted through the working port. Under direct vision, the stone is grasped within the basket and the stone is pulled back against the end of the scope. The retrieval basket, scope, and stone are removed from the common bile duct and then cystic duct as one unit. The stone is then released in the abdomen in a convenient location where it can be found later for removal with the gallbladder. When multiple stones are present, this process is repeated until the ducts are cleared. There are times when the scope can be advance directly into the cystic duct as the initial step. Frequently, it is easier and less frustrating to simply begin again with placement of the 5 french catheter, followed by the guide wire, then the choledochoscope. Though this entails more steps and movements, it can be much more reliable and less time consuming than inserting the scope directly into the cystic duct.

Tranter SE, Thompson MH. Spontaneous passage of bile duct stones: frequency of occurrence and relation to clinical presentation. Ann R Coll Surg Engl. 2003 May;85(3):174-7.

Petelin J B. Laparoscopic Common Bile Duct Exploration. Surg Endosc (2003) 17 (11), pp. 1705-1715

Carroll BJ, Phillips EH, Rosenthal R, Liberman M, Fallas M Update on transcystic exploration of the bile duct.Surg Laparosc Endosc. 1996 Dec;6(6):453-8.

Collins C, Maguire D, Ireland A, et al. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg 2004;239:28–33.

Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones. Gut 5 Mar 2008;57:1004–21.

Martin DJ, Vernon DR, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2006;(2). Art. No.: CD003327. 10.1002/14651858.CD003327.pub2.

Petelin JB, Pruett CS. Common bile duct stones. In: Cameron JL, editor. Current surgical therapy. 8th edition. Philadelphia: Elsevier Mosby; 2004. p. 392–9.

Jennifer E. Verbesey, MD,et al, Common Bile Duct Exploration for Choledocholithiasis , Surg Clin N Am 88 (2008) 1315–1328

Matthew Kroh, MD, Choledocholithiasis, Endoscopic Retrograde Cholangiopancreatography, and Laparoscopic Common Bile Duct Exploration, Surg Clin N Am 88 (2008) 1019–1031