Surgical Options for CBDE  & Choledocholithiasis

Common bile duct exploration and stone extraction is typically problematic, tedious, and is accomplished via three surgical options:

2. Endoscopic Retrograde Cholangio-Pancreatography (ERCP), a second procedure that requires an endoscopic specialist (often not available in smaller hospitals), with a 10% complication risk that includes pancreatitis and a 1.0% mortality rate. Patients who develop post ERCP pancreatitis can expect extended hospital stays of 48-94 days. (Waknine, Yael. Gut, Dec. 2003)

3. Laparoscopic Common Bile Duct Exploration (LCBDE) includes either (a) transcystic or (b) choledochotomy procedures and is a minimally invasive operation with the lowest associated morbidity & mortality. No second operation is required and the patient's diseased gall bladder is removed during the same procedure. LCBDE provides for quick recovery, a short hospital stay (may even be performed in the ambulatory surgery setting), and has virtually no risk of pancreatitis.

Operative cholangiogram showing stones in CBD Click to Enlarge

Transcystic LCBDE vs. Choledochotomy LCBDE

Transcystic LCBDE:

• A very simple technique to master using the video choledochoscope
• Any surgeon that can perform a cholangiogram should be able to safely perform a trans-cystic LCBDE using MIG, 2.8 mm flexible choledochoscope and nitinol stone basket
• The choledochoscope is introduced into the larges lumen of the MIG, the small lumens are plugged
• The MIG protects the choledochoscope as it is passed through port valves
• The MIG is used to guide the choledochoscope into the cystic duct
• A pressure irrigation line is attached to the working channel of the choledochoscope
• The 120 cm x 1.9 Fr. Nitinol stone basket is passed through a Sure Seal valve down the working channel of the choledochoscope while saline pressure irrigation is flowing. The stone is engaged under videoscopic guidance
• No need for T-tube or drains
• Can be performed as an outpatient procedure
• Adds on average only thirty minutes to a laparoscopic cholecystectomy
• Much less risk of pancreatitis than with ERCP
• Patient selection is key, note the simplified procedural algorithm!
• Surgeon's time is well reimbursed

Choledochotomy LCBDE:

• Anterior choledochotomy allows for removal of large stones
• Removal of multiple stones is much less problematic
• Proximal and distal bile ducts easily inspected
• Multiple Instrument Guide (MIG) allows for insertion of choledochoscope and balloon catheter or lithotripter into CBD while irrigation is infusing into CBD
• Allows the complete inspection of the biliary tree and reduces need for ionizing radiation
• Larger diameter instruments may be used
• T-tube allows for drainage of biliary tree for prolonged periods, and is much better tolerated than the naso-biliary catheter. Preferred method of drainage in treatment of cholangitis
• Primary repair of the choledochotomy is acceptable when there is complete clearance of stone, mild inflammation with no evidence of cholangitis, and confirmed patency of the Ampulla of Vater
• The Ampulla of Vater is not cut or damaged as with papillotomy
• Less risk of pancreatitis than seen with ERCP and papillotomy
• Requires laparoscopic suturing

Conclusion: Both laparoscopic choledochotomy and cystic duct approach are feasible approaches to LCBDE and are superior to ERCP in terms of patient safety and cost. Laparoscopic choledochotomy is the preferred procedure for LCBDE and stone extraction in difficult cases such as those with multiple or larger stones, with stones in intrahepatic ducts, in the presence of cholangitis, or in the presence of a small, brittle, or avulsed cystic duct.