Common Bile Duct Exploration in the Era of Laparoscopic Surgery

Objective: To review the treatment and outcome of patients with common bile duct (CBD) stones who underwent cholecystectomy.

Design: Prospective series of 700 consecutive laparoscopic cholecystectomies, with a mean follow-up of 22 months.

Setting: University-affiliated community hospital.

Patients: Eighty patients with documented CBD stones during a 42-month period (July 1990 to January 1994).

Interventions: Laparoscopic CBD exploration (LCBDE) was performed with either choledochotomy and T tube (n = 27) or transcystic duct choledochoscopy (n = 33). Open CBDE (OCBDE) (n = 16) and endoscopic sphincterotomy (n = 16) were also employed.

Main Outcome Measures: Documented removal of CBD stones and procedure-related complications.

Results: Laparoscopic CBDE was successful in 60 (94%) of 64 attempted cases. Mean operating time was 149 +/- 40 minutes and length of hospital stay was 2.8 +/- 2.1 days. Six complications (10%) were recorded, including three retained stones (5%). In 11 of 16 patients undergoing OCBDE, CBD stones were discovered with intraoperative cholangiography after conversion to laparotomy was needed for completion of the cholecystectomy. One OCBDE was planned in a patient with suppurative cholangitis. Preoperative endoscopic sphincterotomy (n = 11) was successful in four patients. Postoperative endoscopic sphincterotomy (n = 5) was successful in four patients.

Conclusion: With a protocol of routine cholangiography, LCBDE, and selective use of OCBDE (when LCBDE is not possible), the reliance on a second procedure (endoscopic sphincterotomy) can be minimized. Laparoscopic CBDE, a technically demanding operation, is possible at the time of laparoscopic cholecystectomy in the majority of cases, with a low complication rate and a short length of hospital stay.