Donald E. Wenner MD
Paul R. Whitwam MD
David Turner MD
Surgical Category: Minimal Access Surgery or Liver, Biliary Tract, Pancreas Surgery
Abstract
Introduction: The laparoscopic approach to difficult cases of choledocholithiasis involving large, multiple, impacted, fibrin embedded, and hepatic duct stones has been problematic. Many of these cases have required conversion to open common bile duct exploration or to biliary enteric bypass. Endoscopic Retrograde cholangio-pancreatography and endoscopic retrograde sphincterotomy have been no more successful than laparoscopic common bile duct exploration in remedying these cases. We describe our experience using the multi-channel instrument guide and the flexible choledochoscope along with the electro-hydraulic or laser lithotripter in these difficult cases.
Method: Laparoscopic common bile duct exploration was attempted in all patients that had choledocholithiasis demonstrated on dynamic fluoroscopic intraoperative cholangiogram. This study focused on a subset of these patients with features that included large (>1 cm), multiple, impacted, fibrin embedded, or hepatic duct stones. The results of laparoscopic common bile duct exploration on these difficult cases are summarized. A choledochotomy approach using the multi-channel instrument guide and the flexible 2.8 mm choledochoscope along with irrigation catheter, balloon catheter, and either the electro-hydraulic or laser lithotripter was used.
Results: A total of 22 patients fulfilled study inclusion criteria. Laparoscopic common bile duct exploration was successful in clearing the bile duct of stones in all but one case. The multi-channel instrument guide lends itself to a variety of unique procedural techniques that are very effective in these difficult cases. These techniques include the use of the multi-channel instrument guide with balloon catheter deployed under video guidance and the use of the multi-channel instrument guide along with irrigation catheter, choledochoscope and lithotripter. The choledochoscope was used to inspect the proximal and distal bile duct in all cases.
Discussion: Using the multi-channel instrument guide along with the video choledochoscope proved to be an effective and reliable way to remedy the most difficult cases of choledocholithiasis. The technique has proven itself to be more reliable than conventional laparoscopic common bile duct exploration techniques or endoscopic techniques. The entire biliary tree, both proximal and distal was inspected in 100% of these cases using the video choledochoscope. The only failure to remove all stones occurred early in our experience in a case with multiple impacted stones, likely as a result of inadequate inspection of the hepatic ducts. The 2.8 mm choledochoscope has proven itself to be the ideal size to inspect the biliary tree.