Prior to the introduction of laparoscopic cholecystectomy choledocholithiasis was documented in approximately 9-16% of those patients who presented for open cholecystectomy. The incidence of common bile duct (CBD) stones remains around 10% today. Definitive treatment of these patients includes cholecystectomy and clearance of the ductal system. In 1890, nearly eight years after Langenbuch performed the first open cholecystectomy; Courvoisier showed that indeed the CBD could be cleared at the time of cholecystectomy. Around one hundred years later, laparoscopic cholecystectomy (LC) became the standard of care for treatment of symptomatic gallbladder disease. Within a few years, several laparoscopic techniques proved successful in the treatment of choledocholithiasis at the time of laparoscopic cholecystectomy.
Common bile duct stones may be found preoperatively, intraoperatively, or post-operatively.
Here, the clinician must decide whether to attempt ductal treatment, i.e. endoscopic retrograde cholangiography and extraction with or without sphincterotomy, before operation or to proceed directly with laparoscopic cholecystectomy (LC) and laparoscopic common duct exploration (LCDE).
An abnormal intraoperative cholangiogram or sonogram is the most common indication for laparoscopic common bile duct exploration. Preoperative studies, including unexplained elevated liver function tests, a dilated ductal system, sonographic evidence of bile duct stones, scintigraphic, endoscopic, or radiographic evidence of common bile duct obstruction, or history of biliary pancreatitis may also warrant laparoscopic common bile duct exploration.
Laparoscopic common bile duct exploration may be accomplished through the cystic duct or through a choledochotomy. Stone size, configuration of the cystic duct-common duct junction, the course of the cystic duct, and the diameter of each of the ducts affect the decision as to which approach is best in a particular case. If a transcystic approach appears feasible, it is usually tried before choledochotomy, because it is less invasive and is associated with better patient satisfaction.
Morbidity associated with LCDE occurs in approximately 8 to 10% of patients, and includes those problems typically associated with general surgery and laparoscopy: nausea, diarrhea, ileus, ecchymosis, atelectasis, fever, phlebitis, urinary retention, urinary tract infection, wound infection/inflammation, biliary leak, dislodged T-tube, sub-hepatic fluid collection, pulmonary embolus, and myocardial infarction. It is generally believed that the incidence of complications is less with a laparoscopic approach than an open approach to common bile duct stones.
Mortality associated with LCDE is zero to 1% in the hands of experienced laparoscopic biliary tract surgeons. This incidence is similar to that found in open surgery and relates more to the general health status of these patients than to laparoscopic common bile duct exploration.