Laparoscopic Common Bile Duct Exploration

Laparoscopic cholecystectomy has become the procedure of choice for laparoscopically skilled surgeons when dealing with both chronic and acute cholecystitis. When choledocholithiasis is encountered in the treatment of these patients the skilled laparoscopist has several treatment options available to treat the patient in one stage and avoid the morbidity of endoscopic sphincterotomy. Although still controversial, laparoscopic common bile duct exploration has been shown to be safe, applicable, and cost-effective in the treatment of choledocholithiasis. This report details several laparoscopic treatment alternatives for choledocho- lithiasis. The modern treatment of choledocolithiasis began during the late 1880s with the introduction of cholecystectomy. At that time common bile duct (CBD) stones were forced distally through the ampulla, proximally out the cystic duct stump, or crushed to facilitate spontaneous passage. Thorton and Abbe changed treat- ment standards in 1889 when they described choledochotomy and direct removal of stones. During the late nineteenth and early twentieth centuries intraoperative management of CBD stones was guided by the subjective clinical experience of the operating surgeon until the introduction of intraoperative cholangiography by Mirizzi in 1937 (1). With the advent of cholangiography negative common bile duct exploration (CBDE) rates fell from around 50% to 6% (2). The incidence of retained CBD stones also decreased from 25% to approximately 11%. Although not popu- larized until the late 1970s, the introduction of the rigid chole- dochoscope by McIver in 1941 further reduced the incidence of retained calculi (3). A significant advance in the treatment of retained stones occurred in 1974 with the introduction of endo- scopic sphincterotomy (ES) (4, 5). With a success rate of 95%, morbidity of 15%, and mortality of 1%, skilled endoscopists changed the significance and treatment of retained calculi. With the introduction of laparoscopic cholecystectomy in 1989, the surgical approach to patients with biliary disease changed. Preoperative endoscopic retrograde cholangiography (ERC) be- came the standard of care for patients suspected of having CBD calculi to avoid open CBDE. During this period postoperative ES increased because of decreased utilization of intraoperative cholangiography. Postoperative ES then became the treatment of choice in patients with CBD calculi documented intraoperatively or discovered later postoperatively. Now that surgeons are more experienced in laparoscopic techniques, less reliance is placed on ES for the treatment of CBD stones. Surgeons can learn the various techniques of laparoscopic CBDE to treat their patients in one session. As laparoscopic suturing skills have developed, so has the technique of laparo- scopic choledochotomy. The most frequently used approach, however, is transcystic common bile duct exploration (LTCBDE). Many transcystic approaches have been developed including biliary balloon catheters, lavage, and trolling with wire baskets. Dilation of the cystic duct allows biliary endoscopy, antegrade sphincterotomy, lithotripsy, catheter placement, and stone re- trieval with wire baskets under direct visualization.