Prof. Dr. R. K. Mishra INTRODUCTION Laparoscopic exploration of the common bile duct (CBD) is performed either for the diagnosis or the treatment of CBD stones. CBD stones demonstrated by laparoscopic intraoperative cholangiography (IOC) or laparoscopic ultrasonography (LUS) are extracted either through the cystic duct or through choledochotomy. An alternative for the treatment of CBD stones is to perform an endoscopic sphincterotomy either before, during, or after laparoscopic cholecystectomy. The main advantages of IOC during cholecystectomy are: ■ Detection of CBD stone ■ Reduction of the incidence of residual CBD stone ■ Delineation of the biliary anatomical variations at risk for bile duct injury Intraoperative cholangiogram is a highly sensitive tool for detecting choledocholithiasis, with an overall accuracy of 95%. Routine IOC can diagnose unsuspected CBD stone in 1–14% (average 5%) of patients without indications for ductal exploration. INTRAOPERATIVE CHOLANGIOGRAPHY Techniques of Cholangiography Cholangiograms obtained during laparoscopy are usually performed after catheterization of the cystic duct through a cholangioclamp (Storz Endoscopy, USA), or inserting a catheter through a hollow gasketed needle pinned through the abdominal wall along the right subcostal margin. Difficulties in catheterization of the small cystic duct have led to consider cholecystocholangiography by direct puncture of the gallbladder as an alternative to cystic duct cholangiography. Cystic duct cholangiography is clearly better than cholecystocholangiography, and fluoroscopic imaging should be the standard for IOC. Until now, no specific clinically significant complications directly attributable to laparoscopic IOC have been reported. Expected success rates for laparoscopic IOC are in a 90–100% range. Inability to cannulate a narrow cystic duct is the main cause of failure. When performed after clipping (but not cutting), the anatomical structures identified by careful dissection such as the cystic artery and the cystic duct, a correctly interpreted IOC allows the detection of the most frequently reported cause of CBD injury, i.e., mistaken identification of a narrow main bile duct in place of the cystic duct. LAPAROSCOPIC ULTRASONOGRAPHY Several studies on LUS have been published and conclusions of these studies favor LUS as compared to IOC. LUS is performed with a higher success rate, in less time, with better specificity, but with less precision with regard to the delineation of biliary tree anatomy. LUS is of little, if any, helps in the diagnosis or prevention of bile duct injuries. While detection of smaller stones by LUS should increase its sensitivity, most of these stones are reputed to be flushed out through the sphincter and therefore the question arises if such small stones require any treatment at all. Specificity of LUS is higher (less false positives) than of IOC. When IOC and LUS were combined, there is chance of less than 1% of false positives. The question that comes to mind is whether LUS should be a screening test, and IOC performed only in case of doubt or should IOC be the screening test, and LUS used only when IOC is of doubtful value? IOC performs better than LUS to delineate the entire biliary tree, from the intrahepatic tree to the pancreatic portion of the CBD. Injection of saline into the biliary tree enhanced the images obtained by LUS, especially in the distal portion of the bile duct. Criteria for Routine Intraoperative Cholangiography Preoperative Factors ■ Failed endoscopic retrograde cholangiography ± sphincterotomy ■ Ultrasonographic findings ■ CBD size (>6 mm) ■ Choledocholithiasis ■ History of jaundice or pancreatitis ■ Elevated bilirubin, alkaline phosphatase, and transaminases
Intraoperative Factors ■ Unclear anatomy ■ Conversion to open cholecystectomy ■ Dilated cystic duct over 4 mm LAPAROSCOPIC EXTRACTION OF COMMON BILE DUCT STONES Once detected during laparoscopic IOC, laparoscopic extraction of CBD stones is a logical extension of the procedure. Laparoscopic exploration of the CBD can be performed either through the cystic duct or by laparoscopic choledochotomy. A critical evaluation of the retrospective and prospective series on laparoscopic CBD exploration published since 1989 shows that both procedures are feasible and safe. Any comparisons between the two techniques would be fallacious because of their obviously different indications. Nonetheless, whenever feasible, laparoscopic transcystic CBD exploration best fulfills the expectancy of mini-invasive approach. Laparoscopic management of CBD stones is considered as technically difficult and demanding, requiring advanced laparoscopic skills as well as expensive endoscopic and radiological equipment. Endoscopic sphincterotomy is commonly proposed preoperatively as the alternative to surgery for CBD stones. Endoscopic sphincterotomy is indicated in patients with severe cholangitis for urgent drainage of infected bile, and in patients with retained stones after cholecystectomy. In open conventional surgery, controlled studies have not shown that ES, performed prior to surgery in patients with CBD stones in situ, was superior to single-step surgical management. In case of preoperative diagnosis of CBD stone, options for management include: ■ Preoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy followed by laparoscopic cholecystectomy ■ Conventional open CBD exploration ■ Laparoscopic CBD exploration Today, most of the laparoscopic surgeons prefer the ‘‘single-stage’’ laparoscopic approach to choledocholithiasis. None of the randomized trials published to date concluded superiority of endoscopic treatment alone or associated with surgery as compared to first-line surgical treatment. Immediate postoperative mortality was 2.6% in the endoscopic group as opposed to 1% in the surgical group. In global analysis, the rate of major and minor complications were respectively 8% and 10% after endoscopy followed by surgery, and 8% and 15% after surgery alone. Study of European Association for Endoscopic Surgery (Table 1) Choledocholithiasis is found in approximately 10–20% of patients who undergo open cholecystectomies. In the TABLE 1: Study of European Association for Endoscopic Surgery (EAES). LCBDE (ERC ± ES) + LC Patients (N) 133 136 With CBD 109 (82%) 99 (73%) Failed ERCP ± ES 23 (17%) Stone clearance 82/98 (84%) p Successful LCBDE NS 92/109 (84%) 12/17 (71%) Conversions 14 (13%) 5 (5%) NS Postoperative ES 3 NS Complications 21/133 17/136 Deaths 0 2 Hospital stay (range) 6.4 (4.2–12) 9 (5.5–14) <0.05 (ES: endoscopic sphincterotomy; LC: laparoscopic cholecystectomy; ERCP: endoscopic retrograde cholangiopancreaticography; LCBDE: laparoscopic common bile duct exploration; NS: nonsignificant) era of laparoscopic cholecystectomies, the prevalence of CBD stones averages 6% (range: 3–10%). The incidence of choledocholithiasis increases over the age of 60 years. To achieve a maximal benefit to risk ratio, radiological investigations of the CBD should be restricted to patients with high suspicion of CBD stones, as determined by preoperative predictive scoring. Diagnostic and therapeutic choices in cholelithiasis must be considered conjointly. Data gathered from randomized trials have demonstrated that endoscopic sphincterotomy, as an additional procedure to surgery, does not improve the clinical results in patients fit for primary single-stage surgical treatment, whether performed laparoscopically or not. Discussions regarding the optimal way to treat patients with demonstrated CBD stones could lead to endless debate. Due to marginal differences between the endoscopic and surgical techniques, the number of patients needed to show any significant difference in terms of morbidity, mortality, or clearance rates would be enormous and therefore unrealistic. Cholangitis, jaundice, and CBD stones, as demonstrated on percutaneous ultrasonography, are the only reliable preoperative indicators available with predictive value of CBD stones better than 50%. Severe cholangitis is an unquestionable indication for urgent endoscopic drainage, regardless of whether the CBD can be cleared of associated stones or not. The notorious insufficiencies of all other preoperative indicators for CBD stones should lead to a requiem for preoperative invasive diagnostic procedures, both in terms of risk, benefits, and costs. Laparoscopic common bile duct exploration (LCBDE) can be performed via the cystic duct (transcystic approach) or an incision in the CBD (choledochotomy approach). In general, small distal stones are best suited for transcystic removal, while large or proximal stones may require a 199
SECTION 2: Laparoscopic General Surgical Procedures choledochotomy approach. All surgeons undertaking laparoscopic cholecystectomy must be able to perform an IOC. When IOC demonstrates CBD stones, appropriate treatment is decided according to available equipment and skills. Transcystic clearance of CBD stones is successful in at least two of three patients. In case of large (>20 mm) stones or other potential difficulties as regards postoperative endoscopic sphincterotomy such as a periampullary diverticulum, conversion to open surgery is indicated in case of failed laparoscopic CBD exploration. In the other cases, the available data do not allow any formal conclusions regarding the alternative between advanced laparoscopic biliary explorations and postoperative endoscopic sphincterotomy. The potential risk of reoperation in case of failed postoperative endoscopic sphincterotomy might be more theoretical than practical. In one decision analysis, assessing different approaches to using ERC in patients undergoing laparoscopic cholecystectomy, postoperative ERC was associated with less costs and morbidity, but laparoscopic CBD exploration was not considered in the study design. Last, before embarking on a more invasive laparoscopic CBD exploration policy for small stones, irretrievable by the transcystic approach, surgeons must remember that asymptomatic migration does exist, even if the definitive fate of small CBD stones remains unknown at the present time. The potential security afforded by temporary biliary drainage still has to be balanced with its unavoidable morbidity. PROCEDURE Patient Position Patient is operated in the supine position with a steep head-up and left tilt. This typical positioning of laparoscopic choledochotomy should be achieved once the pneumoperitoneum has been established (Fig. 1). Port Position The standard four-port configuration for laparoscopic cholecystectomy is used. A fifth port should be used later Fig. 1: Patient position for laparoscopic choledochotomy. between the right midclavicular and epigastric port just below the subcostal margin for inserting the choledochoscope. The fundus of the gallbladder should be retracted toward the right shoulder and the Hartmann’s pouch should be retracted anterolaterally toward right anterior–superior iliac spine. Dissection began onto the neck of the gallbladder and continued proximally until the junction of gallbladder with the cystic duct is clearly defined. Dissection should be continued proximally onto the cystic duct until there was adequate length to perform cholangiogram. Cystic duct should be milked toward the gallbladder to dislodge any cystic duct stone into the gallbladder. Single titanium clip should be applied on the gallbladder side of cystic duct to prevent any back slippage of gallstone into the CBD and to prevent biliary spillage into the operative field. A small nick in the cystic duct should be given with the help of hook scissors or microscissors. Intraoperative cholangiogram should be performed using a ureteric catheter (4–5 Fr) or an infant feeding tube (no. 5–6), which is passed through the cystic duct into the CBD. After the insertion of the catheter, a titanium clip should be applied loosely to prevent any back leakage of the contrast medium. Digital C-arm fluoroscopy provided the real-time imaging of the biliary tree. In cases where the cystic duct could not be cannulated, contrast was directly injected into the CBD through a 24-Fr lumbar puncture needle percutaneously. On cholangiogram, surgeon must look for any filling defect—its size, site, number of bile duct stones, and free passage of contrast into the duodenum and for any anatomical variation of the biliary tree. Transcystic or transcholedochal approach to remove CBD stones should be decided on the following factors (Table 2). Common bile duct stone should be extracted with the help of Dormia basket/balloon catheter, irrigation/ suctioning, or by simply manipulating bile duct using blunt forceps. After retrieving the stones, the cystic duct stump was closed with clips or extracorporeal knots and the gallbladder was removed in the usual manner. For transcholedochal exploration after opening up of the Calot’s triangle, the anterior surface of the CBD should be dissected carefully and choledochotomy should be performed by a longitudinal incision with the help of endoscopic knife just below the insertion of the cystic duct into the bile duct (Figs. 2A to D). Before giving incision with knife, mild coagulation of serosal surface of CBD can help in preventing oozing (Figs. 3A to D). The single large stone can be retrieved by spontaneous evacuation while incising the bile duct, blunt instrumental pressure with atraumatic forceps can facilitate its easy removal (Figs. 4A to D). In case of multiple stones Dormia basket, Fogarty balloon catheter or irrigation and suction can be used to remove the stone (Figs. 5 and 6).
TABLE 2: Transcystic versus transcholedochal approach for removal of common bile duct (CBD) stone. Transcystic approach Transcholedochal approach >3 mm Recommended Recommended Recommended CBD diameter <7 mm Recommended CBD diameter >7 mm Recommended Recommended Recommended Criteria Findings Diameter of cystic duct <3 mm Diameter of cystic duct Any of these approach Recommended Large stone (>6 mm) Recommended Number of stone <4 Number of stone >4 Recommended Recommended Stone location Proximal Recommended Stone location Distal Recommended Junction of cystic duct with CBD Right lateral Recommended Junction of cystic duct with CBD Left lateral or Stone impacted in ampulla Yes Severe inflammation of CBD Yes Laparoscopic suturing Good posterior Recommended Recommended Recommended Recommended Recommended Recommended A B C D Figs. 2A to D: Endo-knife used to explore common bile duct (CBD). Completion cholangiography or choledochoscopy must be performed to assess any remaining stone. Some surgeons use 5.5-Fr bronchoscope for this purpose but ideally choledochoscope will give more flexibility. Once all the stone is removed, choledochotomy should be closed over a T-tube with interrupted Vicryl suture (Figs. 7 to 9). In case of single stone, primary closure of CBD after assessing the clearance of the CBD can be tried. After bile duct closure, cholecystectomy should be performed in the usual manner. An intrahepatic nasogastric tube drain should be used routinely in this surgery, which is usually removed on days 3–4 as the output decreased below 30 mL/day. 201
SECTION 2: Laparoscopic General Surgical Procedures A B C D Figs. 3A to D: Mild coagulation current applied over serosal surface of common bile duct. A B C D Figs. 4A to D: Bigger single stone can be extracted by milking.
A B C D Figs. 5A to D: Fogarty catheter used to extract stone. A B C D Figs. 6A to D: Choledochoscope with Dormia basket is used to extract stone. 203
SECTION 2: Laparoscopic General Surgical Procedures A B C D Figs. 7A to D: Introduction of T-tube. T-tube Management If a T-tube has been placed, a T-tube cholangiogram is performed 24–48 hours postoperatively. If the initial T-tube cholangiogram shows biliary obstruction or retained stones, the T-tube is left open for 1–2 weeks. If a repeat T-tube cholangiogram shows persistent stone or biliary obstruction, ERCP or interventional radiologic procedure via the T-tube is required to clear the duct. A normal T-tube cholangiogram and liver function tests (LFTs) should be ascertained prior to T-tube removal. In patients with a T-tube, the drain should be kept until a T-tube cholangiogram shows no biliary leak or stenosis. In patients without a T-tube, the drain may be removed after LFTs normalize without bilious drain output; alternatively, an HIDA scan can also be obtained to access the biliary anatomy prior to drain removal. COMPLICATIONS Common complications after laparoscopic exploration are: ■ Bile duct leak ■ Persistent stones ■ Impacted stones ■ Bile duct stricture ■ Pancreatitis Most of the complications are same as found in open CBD exploration. Bile may leak from the cystic duct orifice, cystic duct-CBD junction, or the CBD itself. It occurs in 2–16% of cases. Stones persist in the CBD in 0–5% of patients after surgical CBD exploration. Rarely, severely impacted stones are encountered. Strictures of the bile duct are a longterm complication of CBD exploration that occurs in 0–0.8% of cases. Impacted stones are difficult to remove with Fogarty balloon catheters or wire baskets. Pancreatitis occurs in 0–3% of patients following CBD exploration due to reflux of contrast into the pancreatic duct or ampullary obstruction by stones, edema, or blood clots. In the latter case, ERCP may be required to relieve the obstruction. According to data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, laparoscopic CBD exploration has significantly lower mortality (0.25 vs. 5.5%), surgical site infection rate (1.2 vs. 10%), and overall morbidity rate (3.7 vs. 22%) compared with open CBD exploration. However, the increased morbidity and mortality associated with open exploration may be a reflection of underlying comorbidities or more complicated disease requiring an open approach.
A B C D E F Figs. 8A to F: T-tube is fixed with intracorporeal interrupted surgeons knot. Fig. 9: Diagrammatic representation of T-tube fixation with intracorporeal interrupted surgeons knot. 205
SECTION 2: Laparoscopic General Surgical Procedures BIBLIOGRAPHY 1. Altman DG. Practical Statistics for Medical Research. London, England: Chapman and Hall; 1992. 2. Anciaux ML, Pelletier G, Attali P, Meduri B, Liguory C, Etienne JP. Prospective study of clinical and biochemical features of symptomatic choledocholithiasis. Dig Dis Sci. 1986;31:449-53. 3. Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A, et al. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc. 2014;28:875. 4. Barkun AN, Barkun JS, Fried GM, Ghitulescu G, Steinmetz O, Pham C, et al. Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy. Ann Surg. 1994; 220:32-9. 5. Bates T, Ebbs SR, Harrison M, A’Hern RP. Influence of cholecystectomy on symptoms. Br J Surg. 1991;78:964-7. 6. Behan M, Kazam E. Sonography of the common bile duct: value of the right anterior oblique view. Am J Roentgenol. 1978;130:701-9. 7. Bhargava S, Vashisht S, Kakaria A, Tandon RK, Berry M. Choledocholithiasis: an ultrasonic study with comparative evaluation with ERCP/PTC. Australas Radiol. 1988;32:220-6. 8. Clemets D, Aslan S, Wilkins WE. Common bile duct gallstones, anicteric presentation in the elderly: under-recognized but important. Postgrad Med J. 1990;66:878-9. 9. Cooperberg PL, Li D, Wong P, Cohen MM, Burhenne HJ. Accuracy of common hepatic duct size in the evaluation of extrahepatic biliary obstruction. Radiology. 1980;135:141-4. 10. Cotton PB. Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Am J Surg. 1993;165:474-8. 11. Cuscheri A, Croce E, Faggioni A, Jakimowicz J, Lacy A, Lezoche E, et al. EAES ductal stone study. Surg Endosc. 1996;10:1130-5. 12. DePaula AL, Hashiba K, Bafatto M. Laparoscopic management of choledocholithiasis. Surg Endosc. 1994;8:1399-1403. 13. Diehl AK, Sugarek NJ, Todd KH. Clinical evaluation for gallstone disease: usefulness of symptoms and signs in diagnosis. Am J Med. 1990;89:29-33. 14. Dorman JP, Franklin ME Jr, Glass JL. Laparoscopic common bile duct exploration by choledochotomy: an effective and efficient method of treatment of choledocholithiasis. Surg Endosc. 1998;12:926-8. 15. Edwin B, Rosseland ARR, Trondsen E. Prophylactic endoscopic sphincterotomy as treatment. Hepatogastroenterology. 1993; 40:550-5. 16. Ferzli GS, Hurwitz JB, Massaad AA, Piperno B. Laparoscopic common bile duct exploration: a review. J Laparoendosc Surg. 1996;6:413-19. 17. Gigot JF, Navez B, Etienne J, Cambier E, Jadoul P, Guiot P, et al. A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones. Surg Endosc. 1997;11:722-8. 18. Gilliland TM, Traverso LW. Modern standards for comparison of cholecystectomy with alternative treatments for symptomatic cholelithiasis with emphasis on long-term relief of symptoms. Surg Gynecol Obstet. 1990;170:39-44. 19. Graham SM, Flowers JL, Scott TR. Laparoscopic cholecystectomy and common bile duct stones. Ann Surg. 1993;1:61-7. 20. Gross BH, Harter LP, Gore RM, Callen PW, Filly RA, Shapiro HA, et al. Ultrasonic evaluation of common bile duct stones: prospective comparison with endoscopic retrograde cholangiography. Radiology. 1983;146:471-4. 21. Hand DJ. Discrimination and Classification. New York, NY: John Wiley and Sons; 1976. 22. Hauer-Jensen M, Karesen R, Nygaard K, Solheim K, Amlie E, Havig O, et al. Predictive ability of choledocholithiasis indicators: a prospective evaluation. Ann Surg. 1985;202:64-8. 23. Hauer-Jensen M, Karesen R, Nygaard K, Solheim K, Amlie E, Havig O, et al. Consequences of routine preoperative cholangiography during cholecystectomy for gallstone disease: a prospective, randomized study. World J Surg. 1986;10: 996-1002. 24. Houdart R, Perniceni T, Darne B, Salmeron M, Simon JF. Predicting common bile duct lithiasis: determination and prospective validation of a model predicting low risk. Am J Surg. 1995;170:38-43. 25. Hunt DR, Reiter L, Scott AJ. Preoperative ultrasound measurement of bile duct diameter: basis for selective cholangiography Aust N Z J Surg. 1990;60:189-92. 26. Hunt DR, Scott AJ. Changes in bile duct diameter after cholecystectomy: a 5-year prospective study. Gastroenterology. 1989;97:1485-8. 27. Hunter JG. Laparoscopic transcystic common bile duct exploration. Am J Surg. 1992;163:53-8. 28. Jennrich RI. Stepwise discriminant analysis. In: Enslein K, Ralston A, Wilf H (Eds). Statistical Methods for Digital Computers. New York, NY: John Wiley and Sons; 1979. 29. Jorgensen T. Abdominal symptoms and gallstone disease: an epidemiological investigation. Hepatology. 1989;9:856-60. 30. Kelly TR. Gallstone pancreatitis: the timing of surgery. Surgery. 1980;88:345-50. 31. Lacaine F, Corlette MB, Bismuth H. Preoperative evaluation of the risk of common bile duct stones. Arch Surg. 1980;115: 1114-6. 32. Larson GM, Vitale GC, Casey J, Evans JS, Gilliam G, Heuser L, et al. Multi-practice analysis of laparoscopic cholecystectomy in 1,983 patients. Am J Surg. 1991;163:221-6. 33. Liberman MA, Phillips EH, Carroll BJ, Fallas MJ, Rosenthal R, Hiatt J. Cost-effective management of complicated choledocholithiasis: laparoscopic transcystic duct exploration or endoscopic sphincterotomy. J Am Coll Surg. 1996;182:488-94. 34. Mjaaland O, Raeder J, Aaseboe V, Trondsen E, Buanes T. Outpatient laparoscopic cholecystectomy, patient satisfaction and safety: prospective study of 200 patients. Br J Surg. 2007;31:1010-5. 35. Naude GP, Stabile BE, Bongard FS. Antegrade laparoscopic common bile duct stone removal using a balloon-tipped embolectomy catheter. J Am Coll Surg. 1997;184:655-7. 36. Neoptolemos JP, Carr-Locke DL, Fossard DP. Prospective randomized study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones. BMJ. 1987;294:470-4. 37. Neuhaus H, Feussner H, Ungeheuer A, Hoffmann W, Siewert JR, Classen M. Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystography. Endoscopy. 1992;24:745-9. 38. Niederau C, Sonnenberg A, Mueller J. Comparison of the extrahepatic bile duct size measured by ultrasound and by different radiographic methods. Gastroenterology. 1984;87:615-21. 39. Noble H, Tranter S, Chesworth T, Norton S, Thompson M. A randomized, clinical trial to compare endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholithiasis. J Laparoendosc Adv Surg Tech A. 2009;19:713. 40. O’Connor HJ, Bartlett RJ, Hamilton I, Ellis WR, Watters JK, Lintott DJ, et al. Bile duct calibre: the value of ultrasonic and cholangiographic measurement in the postcholecystectomy patient. Gut. 1984;25:A576.
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