Over the years, for gallstone disease, laparoscopic cholecystectomy (LC) is an established procedure as gold standard. Approximately 9%–16% of patients with gallbladder stones have concomitant common bile duct (CBD) stones. The two-stage endo-laparoscopic approach (LC with preoperative endoscopic retrograde cholangio-pancreatography – [ERCP]) has been widely adopted as standard practice for managing gallstones with CBD stones. It has replaced traditional open choledocholithotomy and cholecystectomy.
Laparoscopic CBD exploration (LCBDE) with LC is performed at few centres with adequate surgical expertise. One-stage LCBDE and stone removal during LC has proven to be equivalent to the two-stage approach, but with a shorter hospital stay. A recent meta-analysis of randomised trials made similar conclusions. Herein, we present the result of our experience using LC and LCBDE as a single-stage procedure for managing gallstones with CBD stones.
PATIENTS AND METHODS
A retrospective analysis of prospectively recorded data of 121 consecutive patients was performed from February 2010 to December 2019, who underwent LC and LCBDE by choledochotomy in a single surgical unit [Table 1].
The study included patients diagnosed with cholelithiasis and choledocholithiasis on imaging. USG was the first line of imaging and was performed in all the patients. Magnetic resonance cholangio-pancreatography was obtained in patients with suspected ductal stones (based on CBD dilatation on ultrasound and deranged liver function suggestive of bile stasis). All these patients underwent ERCP by the gastroenterology team at our center, but complete ductal clearance could not be achieved. The reasons for failed ERCP included large CBD stones, CBD studded with stones, simultaneous stones in CBD and both hepatic ducts, CBD stone with an impacted stent or inability to cannulate CBD [Table 2]. Two of these patients had the Dormia basket impacted in the CBD when using it for ductal stone clearance, and the procedure had to be abandoned. These patients underwent LCBDE with the mean time interval between ERCP and CBD exploration being 1.6 ± 0.5 days (range 1–5 days).
Patient data were collected using case records, operation notes and follow-up data with regard to complications, residual stones and recurrent stones.
The conventional four-port configuration of LC was used. A 10-mm fifth port was made between the right midclavicular and epigastric port just below the sub-costal margin for CBD exploration. The procedure was started as for any standard LC. The fundus of the gallbladder was retracted towards the right shoulder. Calot's triangle was dissected, and a 'critical view of safety' was obtained. The cystic artery was clipped and divided. Then, the cystic duct was clipped. The CBD was dissected carefully and confirmed by demonstrating bile aspiration using a 22G or 23G scalp vein set [Figure 1]. Choledochotomy was performed on the anterior surface of CBD by giving a longitudinal incision (1 cm or more depending on stone size) just below the cystic duct-CBD junction using an endoscopic monopolar hook or knife.
CBD exploration was done most commonly using a nephroscope [Figure 2]. Other scopes used included GI endoscope [Figure 3], ureteroscope, and hysteroscope [Table 3]. Lower CBD was explored through a 10-mm incision between right midclavicular and epigastric ports, and umbilical port site incision was used to explore proximal CBD and both right and left hepatic ducts. Stone removal was done using Triprong or tooth graspers [Figure 4], Fogarty's balloon catheter, Dormia basket or LithoClast.
After confirming complete CBD clearance by choledochoscopy, primary closure was done using no 3-0 vicryl interrupted sutures with or without T-tube [Figure 5]. T-tube was not used in cases where CBD clearance was confirmed, and papillotomy was wide (confirmed by the scope that could easily negotiate into the duodenum). Four patients had primary closure over previously placed endoscopic CBD stent. Abdominal drain of 28 Fr size was placed in sub hepatic space and all 10-mm ports were suture closed.
The abdominal drain was removed when its volume was <25 ml, serosanguinous in nature, and T-tube was draining bile. Patients were usually discharged on the 3rd or 4th post-operative day (POD). T-tube was removed between 10th and 21st POD after a T-tube cholangiogram to rule out residual stones.
Out of 121 patients, LCBDE was completed in 118 patients, and three patients were converted to open. Of these three patients, one had intra-operative suspicion of malignancy and underwent open CBD exploration after frozen section negative. The second patient had bleeding from choledochotomy, which made it difficult to proceed with LCBDE. The third patient underwent CBD exploration laparoscopically but had an intractable bleed from gallbladder fossa, for which packing had to be done to control the bleed.
These patients either had large CBD stones, CBD studded with stones, simultaneous CBD and hepatic duct stones or stones with an impacted stent [Figure 6], resulting in failure of ERCP to achieve complete ductal clearance.
Seven of these patients were post-cholecystectomy and underwent LCBDE for primary CBD stones (formed 2 years post-cholecystectomy). Two patients underwent LCBDE for CBD stones with impacted Dormia basket after ERCP, which was successfully retrieved [Figure 7]. One patient had accidental portal vein injury as the portal vein was lying anterior to CBD, mistaken as CBD. The repair was performed laparoscopically, followed by LCBDE. It was the only case where CBD was not confirmed by aspiration. Therefore, CBD confirmation is mandatory, by either aspiration or per-operative cholangiogram.
The CBD was closed over T-tube in 103 patients, which was removed after a mean of 14.6 ± 2.4 days after doing a T-tube cholangiogram. Fifteen patients underwent primary suturing of CBD, of which 4 had a stent in situ (placed pre-operatively during ERCP).
The mean hospital stay post-procedure was 3.4 ± 0.7 days. Complete ductal clearance was achieved in 115 patients, and residual stone fragments reported in three patients on T-tube cholangiography were removed by ERCP. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis or cholangitis. There was no 30-day mortality and no recurrent stones or CBD strictures reported with a mean follow-up of 12.4 ± 3.9 months.
Cholelithiasis with concomitant CBD stones is a common scenario faced in the clinical practice. There are various approaches for the management of this pathology. With the availability and advancement of endoscopic training, pre-operative ERCP followed by LC is considered the standard of care. ERCP has its own limitations concerning very large stones which cannot be removed endoscopically or when the ampulla cannot be cannulated due to anatomical challenges. Furthermore, sphincterotomy may lead to late complications, including pancreatitis, bile duct stricture and cholangitis. It may also predispose to cholangiocarcinoma and pancreatic tumours.
Open CBD exploration is associated with morbidity, resulting in delayed patient recovery and prolonged hospital stay. LCBDE can be performed by trans-cystic or choledochotomy approach. The trans-cystic approach has its limitations as it requires a dilated cystic duct, and it might be difficult to remove very large stones (indicated only up to 7–8 mm size stone). The choledochotomy approach has no such limitations. In fact, there is enough literature that considers LCBDE to be superior compared to two-stage endo-laparoscopic approach with respect to higher ductal clearance, shorter hospital stay and lower morbidity. These findings have been confirmed by two meta-analyses and one systematic review. Despite this, LCBDE is still not the first choice for the management of CBD stones as it is technically challenging and requires a high level of expertise.
Our study reports the result of LC-LCBDE over a period of 10 years. Our study included only those patients with failed ERCP (two patients had an impacted Dormia basket after ERCP). Thus, it was even more technically demanding.
After complete CBD clearance, the choledocotomy was closed over T-tube in 103 patients. Closure over T-tube enables us to perform a T-tube cholangiogram to image the biliary system postoperatively. Its disadvantages include accidental dislodgment with the rare possibility of bile leak and peritonitis at its removal. We did not face any major complications with the T-tube, except for late dislodgement in 2 of our cases with no peritoneal sepsis. Primary closure of choledochotomy over stent was performed in four patients, which provides biliary decompression like T-tube but requires follow-up ERCP to remove the stent.
Primary closure of choledochotomy without T-tube has been reported in the literature, with studies reporting it as a safe and feasible alternative to T-tube closure. However, it should be avoided in case of any doubts concerning complete clearance of CBD. In our series, primary closure without T-tube/stent was performed in 11 patients. These mostly included cases with solitary stone which required minimal CBD manipulation and had wide papillotomy. All these cases recovered well without any post-operative issues such as abdominal collection or leak.
The length of hospital stay for LCBDE in most studies range from 1 to 7 days. In our study, patients were usually discharged on 3rd or 4th POD. The mortality of LCBDE has been reported to be 0%–1% in most studies when performed by experienced biliary surgeons. We have no reported mortality, which may be attributed to surgical expertise and case selection.
Our study shows that LCBDE can be performed safely with no significant post-operative complications or long-term sequelae like recurrent stones or bile duct stricture. These findings are similar to certain other studies reported in the literature. Our study is a retrospective analysis of collected data. The limitation of this study is its relatively small sample size, as it includes only those cases with failed ERCP and performed in a single surgical unit.
The technique of the one-stage laparo-endoscopic Rendezvous approach (LERV) for treating gallbladder and CBD stones in the same setting has been reported in literature too that does not require laparoscopic suturing skills or biliary drainage. This approach has shown better outcomes for stone clearance and lower post-procedural pancreatitis rate, as compared to the two-stage treatment. At our center, we have no experience with this technique and it would be worthwhile comparing the two single-stage approaches (LC-LERV versus LC-LCBDE) in future trials for their outcomes, both at short- and long-term follow-up.
LCBDE by choledochotomy approach is safe and an effective single-stage minimally invasive technique for treating GB and CBD stone after failed ERCP. It is associated with a learning curve and requires surgical expertise and experience to avoid morbidity and long-term sequelae.
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Conflicts of interest
There are no conflicts of interest.
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