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Chapter 10
some abdominal pain and none of the 35 patients
referred back to hospital for investigation had evidence of retained ductal stones. Multivariate analysis showed that preoperative flatulence and long
durations of attacks of pain were risk factors for
postoperative dissatisfaction.
Given that the basis for symptoms before
cholecystectomy often remains uncertain, it is
evident that a substantial number of patients
continue to experience problems after operation.
Mini-laparotomy cholecystectomy
In the few years before the advent of laparoscopic
cholecystectomy, there had been a resurgence of
interest in open cholecystectomy through a small
incision, the so-called mini-laparotomy cholecystectomy, in an effort to reduce the trauma of open
surgery.
There have been few controlled trials; of those
that have been performed, one showed laparoscopic cholecystectomy to be superior and the
other showed mini-laparotomy cholecystectomy as
superior.
again confirmed a smoother convalescence for laparoscopic cholecystectomy, although operating times
remained longer.
posure for a fundus-first cholecystectomy carried
out without the surgeon's hands entering the abdominal cavity. Cholangiography is possible but
is not performed in most reports of the technique.
The author's limited first-hand experience of the
technique has not persuaded him that the view of
the cystic duct/CBD junction is comparable to that
achieved by laparoscopic cholecystectomy. The true
incidence of bile duct injury with this technique is
unknown and cannot be equated to the open era of
large incisions.
40,41
The most recent randomised trial has
42
The technique relies on retractors to provide ex-
Symptomatic gallstones
The laparoscopic procedure can be offered to all
patients with symptomatic gallstones, providing
their cardiorespiratory status does not preclude
laparoscopy. Of all patients presenting for operation, 95% can be completed successfully by
laparoscopic means. Obesity, acute inflammation,
adhesions and previous abdominal surgery do not
usually prevent a laparoscopic cholecystectomy,
but may require some adaptations of technique to
complete the procedure.
scopic cholecystectomy have been well described
previously,
43,44
including cases performed under re-
43–51
Techniques of laparo-
gional anaesthesia in patients with chronic pulmonary disease.45 Laparoscopic cholecystectomy has
been widely reported in pregnancy46 and in patients
with cirrhosis.47 In a substantial audit of seven
European centres,
43,44
96% of procedures were
completed successfully in the 1236 patients and
only four bile duct injuries were reported. There
were no postoperative deaths, median hospital stay
was 3 days and the median return to normal activities was only 11 days.
Acute cholecystitis
Fears that laparoscopic cholecystectomy in the
management of acute cholecystitis could carry an
unacceptable risk of disseminating infection or of
perpetrating an injury to the bile duct appear unfounded.51 Several large series report success and
safety with this procedure, although the incidence
of bile duct injury and conversion to open operation remain slightly higher.52 In difficult cases, improvement in the exposure of Calot's triangle may
require additional or different positioning of the
laparoscopic cannulae, the use of oblique viewing
telescopes and placement of endoscopic retractors.
Decompression of a distended or inflamed gallbladder may also improve access.
There is no evidence to support the routine
use of mini-cholecystectomy in the treatment of
symptomatic gallstone disease.
Laparoscopic cholecystectomy
Despite the paucity of randomised controlled trials, enthusiasm for the technique of laparoscopic
cholecystectomy continues unabated, driven predominantly by patient satisfaction, with less pain
and an earlier return to normal activities. Surgeons
are attracted by the excellent view of the gallbladder and biliary tree afforded by the laparoscope,
and health providers and purchasers are attracted
by the short hospital stay, which offers significant
cost savings.
180
Complications
The mortality rate in a good-risk patient undergoing
elective operation is less than 1% and operative risks
usually arise from comorbid conditions. The laparoscopic technique is associated with lower wound
infection rates than open surgery.53 Furthermore, a
recent meta-analysis has shown that antibiotic prophylaxis is not warranted in low-risk patients undergoing laparoscopic cholecystectomy.
54
Day-case laparoscopic cholecystectomy
Worldwide, laparoscopic cholecystectomy is being
performed in the day-case setting with good preoperative patient selection, improved techniques, and
improved postoperative control of pain, nausea and
vomiting.
55
Gallstones
Needlescopic cholecystectomy
This technique has been described using 2- and
3-mm instruments and a 3-mm laparoscope. A
randomised trial has shown less pain and smaller
scars when this technique was used in patients with
chronic cholecystitis.
56
Evolution of technical aspects of multiport exposure, decreasing port sizes and instrumentation continues. There is currently no evidence of a benefit
for single-incision laparoscopic port techniques,57
with impaired ergonomic performance and probable increased incisional hernia rate.
Bile duct injury
Anxieties regarding an increased incidence of bile
duct injury with the introduction of laparoscopic
cholecystectomy have not been substantiated by
multicentre studies from Europe48 and the USA,49
with a reported incidence of injury to the CBD
of 1 in 200–300 cases. In a study in the West of
Scotland, a prospective audit of laparoscopic cholecystectomy was undertaken.58 A total of 5913
laparoscopic cholecystectomies were undertaken
by 48 surgeons, and 37 laparoscopic bile duct injuries were reported. Major bile duct injuries were
defined as those where laceration to more than
25% of the bile duct diameter occurred, where the
common hepatic duct or CBD was transected, or in
those instances when a bile duct stricture developed
in the postoperative period. Of the 37 injuries, 20
were classified in this way, giving an incidence of
0.3%. Delayed identification of bile duct injury occurred in 19 patients and, although it was noted
by the author that cholangiography did not play a
part in the identification of bile duct injuries, it was
noteworthy that imaging was used in only 8.8% of
all laparoscopic procedures. During the course of
this 5-year study, the annual incidence of bile duct
injury peaked at 0.8% in the third year but had
fallen to 0.4% in the final year of the audit. A metaanalysis of more than 100 000 cases reported an injury rate of 0.5%.59 Archer et al. emphasised the
importance of supervised surgical training to allow
attenuation of the trainee surgeon's learning curve
by the experience of his/her proctoring surgeon.
The importance of cholangiography in the early detection of bile duct injury was also emphasised.60
Way et al. analysed bile duct injuries from a cognitive psychological perspective and concluded that
errors that led to bile duct injury stemmed from
anatomical misperceptions as opposed to errors
of skill or judgment (Fig. 10.3). This analysis concluded with a list of rules to help prevent injuries.
61
Cholecystostomy
For patients whose symptoms of acute cholecystitis
did not settle in the past, cholecystostomy was often
undertaken in those cases where open cholecystectomy was thought to carry an unacceptable risk of
injury to the biliary tree. The procedure could be
undertaken under local anaesthesia and, following decompression of the gallbladder and stone
removal, a drain could be left in situ. With the demonstration that acute cholecystectomy could be undertaken safely,52 cholecystostomy has become an
infrequent surgical procedure. The technique now is
most often undertaken percutaneously under ultrasound or CT guidance and is most used in the frail
patient with cardiorespiratory instability requiring
time to control or when anticoagulation precludes
surgery. It may rarely be of value during a difficult
laparoscopic cholecystectomy when the risk of conversion to an open procedure may be considered
unacceptable. In such instances, a drain can be inserted through one of the 5-mm cannulae, which
can be introduced directly into the gallbladder by
reinsertion of a trocar.
Subtotal cholecystectomy
This is another strategy to consider if dense fibrosis
or large vessels are present in the area of Calot's
triangle and the cystic duct is clearly identified and
confirmed by cholecystogram. The cystic duct is ligated and excision of the gallbladder is undertaken,
leaving its posterior wall intact on the liver. This
situation probably arises most in those patients with
cirrhosis and portal hypertension.
Laparoscopic cholecystectomy is associated
with less pain, shorter hospital stay, faster return
to normal activity and less abdominal scarring
than open surgery, and is therefore preferred to
open surgery in the management of symptomatic
gallstone disease.
62
Intraoperative cholangiography (IOC)
The debate over the potential benefit of operative
cholangiography has spanned the open and laparoscopic eras.
Routine IOC
Many surgeons who had previously performed the
technique routinely at open cholecystectomy abandoned cholangiography during laparoscopic cholecystectomy, since it was thought to be too difficult
to undertake. In a large population-based study
in Western Australia, Fletcher et al.63 concluded
that operative cholangiography had a protective
effect for complications of cholecystectomy. In a
large study of over 1.5 million Medicare patients
undergoing cholecystectomy, Flum et al.64 demonstrated that surgeons performing operative cholangiography routinely had a lower rate of bile duct
181
Chapter 10
a
c
Figure10.3 • The ‘classical’ laparoscopic bile duct injury. (a) The common duct is misidentified as the cystic duct and is
doubly clipped. (b) The common duct is then divided. (c) The gallbladder is retracted to the right, stretching the common
hepatic duct and placing it in contact with the gallbladder. This is identified as an accessory duct and double clipped.
(d) A high transection of the common hepatic duct results in the excision of most of the extrahepatic biliary tree.
injuries than those who did not, and this difference disappeared when IOC was not used. The
author believes that operative cholangiography
has an important role in laparoscopic cholecystectomy, not only to detect CBD stones but also to
confirm, beyond doubt, the anatomy of the biliary
tree, since the severity of bile duct injury appears
far greater in laparoscopic surgery. The addition
of cholangiography to the total dissection time of
laparoscopic cholecystectomy is relatively short.
On the basis that the time to learn operative cholangiography is not during the management of a
difficult case, it is recommended that it should be
performed as a routine but should not be seen as
a substitute for careful dissection of the infundib-
b
d
Selective IOC
There are data supporting a selective approach to
IOC at open17 and laparoscopic cholecystectomy.65
Unsuspected stones on routine cholangiography
at laparoscopic cholecystectomy occurred in only
2.9%, and residual CBD stones causing symptoms
in patients not undergoing routine cholangiography
were found in only 0.30%. The strength of any selective policy for IOC will depend on the predictive
values of preoperative investigations. Numerous
studies have examined risk factors for choledocholithiasis but, from multivariate analysis, it would appear that an increased diameter of the CBD and the
presence of multiple (>10) gallstones are the only
significant independent indicators.
17
ulum of the gallbladder and the cystic duct close
to the gallbladder. By dissecting these structures
both anteriorly and posteriorly, the gallbladder is
displaced (sometimes called the ‘flag’ technique,
or ‘critical view’) to enable the surgeon to see behind the gallbladder and thus minimise the risk of
injury to the portal structures. Routine IOC also
improves the surgeon's skills to enable successful
transcystic exploration of the CBD.
Bile duct injury
The principal cause of damage is due to misidentification of the CBD as the cystic duct. As dissection
proceeds an ‘accessory duct’ (in reality the common
hepatic duct) is visualised, clipped and divided, resulting in resection of most of the extrahepatic biliary tree (Fig. 10.3). Operative cholangiography adds
to the certainty that the cannula is in the cystic duct.
182
Gallstones
If only the distal biliary tree is filled, the surgeon is
alerted to the error before any duct is completely
divided. Although critics of operative cholangiography will argue that the CBD has been injured by
the incision through which the cholangiogram catheter is introduced, the injury at this point is recoverable, either by direct suture or insertion of a T-tube
(Fig. 10.4). In the rarer situation when the cystic
duct arises from the right hepatic duct, and dissection has not progressed correctly, cholangiography
identifies such anomalies and helps to avert more
major injury (Fig. 10.5).
Laparoscopic ultrasound (LUS)
The emergence of ultrasound probes that can be
passed down the laparoscopic ports has further
improved the accurate measurement of CBD diameter, as well as the stone load within the gallbladder. Both mechanical sectoral and linear array
laparoscopic ultrasound probes have been shown
to be as useful as cholangiography in the detection
of CBD stones.
consuming, allows less radiation exposure and has
similar failure rates to IOC when performed in welltrained hands. In a large series, the common hepatic
duct and the CBD were identified in 93% and 99%
of cases, respectively. Sensitivity and specificity for
identifying bile duct stones were 92% and 100%,
respectively. A normal CBD diameter at LUS was
also an excellent negative predictor of CBD stones.68
The same authors later concluded that LUS could
66,67
LUS is less invasive, less time-
replace IOC.69 Others feel IOC and LUS should
be seen as complementary tests rather than competitive.70 LUS may facilitate a policy of selective
cholangiography. Despite reports of accurate identification of anatomy it remains to be seen whether
this will translate to prevention of bile duct injury.
A cost benefit also remains to be demonstrated,
given the capital outlay for the equipment.
The use of intraoperative cholangiography
allows detection of CBD stones during
cholecystectomy and when interpreted
appropriately is associated with a lower risk of
CBD injury.
Management of common bile duct stones
The natural history of a given CBD stone remains
difficult to predict. In a prospective study of 1000
cases of symptomatic gallstones it was found that
73% of cases that presented with features suggestive of CBD stones had no CBD stone at the time
of operation and were therefore considered to have
passed the stone spontaneously. Cases of cholangitis or jaundice were less likely to pass stones
spontaneously.
Primary bile duct stones form within the CBD,
usually due to ampullary stenosis, diverticula or
impaired bile duct motility. Management of these
71
a
Figure10.4 • (a) The small-diameter common bile duct has been mistaken for the cystic duct. Only the distal common
bile duct and duodenum are shown, with no proximal filling of the ducts. Recognition of the error at this stage averts
a major injury to the common duct. (b) After further dissection, the cystic duct was identified and a T-tube placed in
the incision in the common duct. A subsequent T-tube cholangiogram confirms the normal anatomy, and laparoscopic
cholecystectomy was completed successfully.
b
183
Chapter 10
a
Figure10.5 • (a) During what appeared
to be a very straightforward laparoscopic
cholecystectomy, the routine operative
cholangiogram showed only the right
hepatic duct and right hepatic biliary tree.
(b) Repositioning of the catheter and the
LigaClip showed the remainder of the biliary
tree and made clear that the structure
initially thought to be the cystic duct was the
distal right hepatic duct below an anomalous
origin of the cystic duct.
b
stones will often require choledochojejunostomy,
depending on the circumstances and patient age.
72,73
Treatment of primary duct stones with choledochotomy and T-tube drainage alone is associated
with recurrence rates up to 41%.74 Laparoscopic
choledochoduodenostomy remains an option for
the advanced laparoscopic surgeon,
75,76
although
there may be concerns regarding the longer-term
consequences of bilioenteric reflux.
Secondary bile duct stones are stones that originate within the gallbladder and are found in the
CBD prior to, at the time of, or within 2 years of
184
cholecystectomy. Approximately 12% of patients undergoing surgery for symptomatic gallbladder stones
will also have stones in the CBD. More than 90% of
these patients will have preoperative indications such
as a history of jaundice or pancreatitis or abnormal
LFTs, but 5–10% have no indication of stones in the
bile duct other than a positive finding (filling defect,
absence of filling of the terminal segment of the common duct, delay or absence of flow into the duodenum) on the perioperative cholangiogram.
The best management of CBD stones is still a mat-
ter of debate.77 Discussion of different practices
Gallstones
is presented here in the order the author considers most practical, and a suggested algorithm is
presented.
Laparoscopic transcystic common bile duct exploration
Laparoscopic CBD exploration has been described through the cystic duct or common duct
using either fibreoptic instruments or radiologically guided wire baskets or balloons.
increased emphasis on improving techniques via
the transcystic route is because of the ease of closure without the added need for intracorporeal
suture technique, combined with postoperative recovery similar to cholecystectomy alone. Careful
evaluation of the CBD diameter and stone load
from the cholangiogram is required to determine
the best approach.
The author's preferred initial method of laparo-
scopic exploration is by fluoroscopic means using
a C-arm image intensifier, which is mobile and
provides dynamic images with angulation. We employ a 5.5-Fr 70-cm radio-opaque nylon catheter
with soft tip and end hole along with a side arm
that connects to a catheter for injection of contrast
(Fig. 10.6). Once the cystic duct is opened for insertion of the cholangiogram catheter, absence of
bile backflow is a signal to milk the cystic duct
backwards to extrude stones caught in transit to
the CBD, rather than push them onwards into the
CBD. A cholangiogram is performed (Fig. 10.7a),
note being taken of the cystic duct and bile duct
78–81
The
diameter, number of stones, stone size and their
distribution in the biliary tree. CBD stones that
appear to be of a size suitable for removal via the
cystic duct and are not too numerous indicate that
transcystic clearance has a high chance of success. Transcystic clearance proceeds by passing a
75- cm-long stone extractor (Cook®, Wilson-Cook
Medical GI Endoscopy Inc., North Carolina). The
basket tip should be positioned well back from the
cannula tip to avoid perforation of the duct. Once
the cannula tip is progressed, under image intensification, the basket is advanced within the cannula
to allow engagement of the stone, which is withdrawn into the basket and extracted via the cystic
duct (Fig. 10.7b). It is useful to remove the proximal
stones first, and vital to avoid opening the basket
within the duodenum or withdrawing through the
ampulla with the basket wires open. Any impacted
stones can be dislodged by passing a 4-Fr Fogarty
catheter beyond the stone and withdrawing the
catheter with the balloon inflated. Failed disimpaction may require choledochoscopy and lithotripsy
(Fig. 10.7c–f, Box 10.1).
Traditionally at open surgery, the common duct
was decompressed postoperatively with a T-tube
until it was known that the bile was draining satisfactorily through the ampulla and there was no bile
leak. Most series of laparoscopic transcystic common duct explorations do not report the routine use
of drainage of the common duct. A subhepatic drain
is routine.
There is accumulating evidence, including three
randomised trials, that 60–70% of patients are able
to have their calculi cleared via the cystic duct.
82–88
Figure10.6 • Composite
cholangiogram catheter and
stone extraction basket used for
laparoscopic transcystic exploration
of the common bile duct. Reproduced
with permission of Cook Australia.
185
Chapter 10
a
c
b
d
e
Figure10.7 • (a) Cholangiogram of a 21-year-old jaundiced patient demonstrating multiple CBD stones with one
impacted 3 cm proximal to ampulla. (b) Fluoroscopic view of bile duct showing after rapid transcystic four-wire basket
retrieval of all except the impacted stone. (c) Transcystic choledochoscopic view of impacted stone, unable to be
dislodged with a balloon catheter. (d) Transcystic ureteroscopic lithoclast stone fragmentation. (e) Wire basket stone
retrieval under vision. (f) Fluoroscopic view of cleared bile duct.
f
186
Gallstones
Box10.1 • Techniques for improving transcystic
clearance
• Careful dissection of cystic duct/CBD junction
• Avoidance of the spiral valves when incising cystic duct
• Careful examination of cholangiogram (‘did that stone pass
through the cystic duct?’)
• Approach cystic duct from different or extra ports
• Choledochoscopy via cystic duct, with lithotripsy if required
• Vary retraction on fundus
Laparoscopic choledochotomy
In up to 35% of patients, laparoscopic transcystic exploration of the CBD will fail to clear the
82–88
CBD.
sidered. The only absolute contraindication to choledochotomy is a CBD diameter of less than 8 mm
(Box 10.2). It should also be borne in mind that approximately one-third of stones detected at cholangiography may be passed spontaneously, and that
exploration of a small duct may result in increased
morbidity for the patient.89 Therefore, laparoscopic
choledochotomy is only an option for appropriately
trained surgeons (Box 10.3).
Once clearance of the duct has been confirmed by
choledochoscopy (see below), a T-tube is inserted
or primary closure can be considered with the insertion of an antegrade stent across the ampulla.82
Antegrade stenting, placement of a T-tube or cystic
Box10.2 • Indications for choledochotomy
• Unsuccessful transcystic exploration
• Cystic duct diameter smaller than size of stones
• CBD diameter >8 mm
• Multiple large stones
• Ampullary diverticulum on IOC
• Previous Billroth II gastrectomy
• Previous failed ERCP
• Contraindication to postoperative ERCP
• ERCP unavailable
Box10.3 • Useful tips in performing laparoscopic
• Deflate duodenum with nasogastric tube (NGT)
• Extra port to retract duodenum
• Leave cholangiocatheter in to prevent deflation
• Sharp scissors choledochotomy
• Intraoperative lithotripsy preferably by lithoclast
Choledochotomy then needs to be con-
choledochotomy
duct tube decompression of the CBD is wise where
doubt exists about free postoperative bile drainage
through the ampulla. This is most likely where a
stone was impacted, ampullary manipulation has
been extensive or in patients with established cholangitis. Placement of a subhepatic drain is essential.
Open choledochotomy
Successful exploration of the CBD can only be
achieved through an adequately sized choledochotomy to facilitate both removal of any obvious
stones and choledochoscopy. The gradual adoption
of operative choledochoscopy during the 1970s and
1980s saw a decline in the incidence of retained
CBD stones following surgery, from about 10% to
1.2%, with a number of surgeons reporting large series of patients with no retained stones.90 On initial
examination of the proximal ducts, it is normally
possible to visualise several generations of ducts
when these are dilated. Once it has been ascertained
that the upper ducts are clear, the distal biliary tree
can be examined. It is mandatory to clearly visualise the rather ragged appearance of the ampulla of
Vater and then withdraw the choledochoscope. If a
stone is visualised it can be retrieved with a stone
basket and the procedure repeated until the duct is
clear. The common duct is closed with or without
a T-tube.91 The latter is probably unnecessary for
an experienced choledochoscopist but, for the less
experienced surgeon, it allows access to the biliary
tree for postoperative cholangiography to confirm
ductal clearance and to allow re-exploration of the
duct without the need for re-operation.
Following the evolution of laparoscopic exploration of the bile duct, the most important area for
laparotomy is for Mirizzi type 2–4 erosion of the
bile duct by large stones and chronic inflammation.
Reconstruction of the bile duct with the remaining
gallbladder wall, or bilioenteric bypass in these circumstances, is best approached by laparotomy.
Endoscopic retrograde cholangiopancreatography (ERCP)
With the advent of laparoscopic cholecystectomy,
ERCP and endoscopic sphincterotomy (ES) have
become the usual procedure for treating common
duct stones, since laparoscopic common duct exploration is not yet a widely practised technique
(Box 10.4). Moreover, cholecystectomy without
cholangiography is commonly performed in the expectation that ERCP and ES will be effective in dealing with unrecognised retained common duct stones
at a later date. Such a policy, however, does expose
the patient to an additional and often unnecessary
187
Chapter 10
Box10.4 • Reasons to consider converting to open
choledochotomy
• Unsuccessful transcystic CBD exploration
• Unsuccessful laparoscopic choledochotomy
• Multiple (>10) CBD stones
• Large CBD stones
• Intrahepatic or proximal ductal stones
• Impacted stones
• Failed or unavailable ERCP
procedure. Laparoscopic common duct exploration
by whatever route has the advantage for the patient
of being able to deal with both gallbladder and CBD
stones at the same time.
92
There is general agreement that endoscopic removal of bile duct stones is preferable to surgery in
postcholecystectomy patients, and in high-risk surgical patients when the gallbladder is still present –
that is, patients with severe acute cholangitis and
selected patients with acute biliary pancreatitis.
93–95
The author believes ERCP becomes an option when
transcystic CBD exploration has failed, but should
not be considered the first-line management of all
CBD stones.
Duct clearance can be expected in 90–95% of patients undergoing successful sphincterotomy, and
this results in an overall success rate for endoscopic
stone clearance of 80–95%, the highest success rates
being recorded as experience increases.
93,95,96
Major
complications occur in up to 10% of patients, and
include haemorrhage, acute pancreatitis, cholangitis and retroduodenal perforation, but the overall procedure-related mortality is less than 1%.93
However, the 30-day mortality can reach 15%,
reflecting the severity of the underlying disease. In
selected patients with calculi less than 15 mm in
diameter, morbidity may be reduced by papillary
dilatation rather than sphincterotomy.94 Difficulties
in removing CBD stones endoscopically may be
due to unfavourable or abnormal anatomy, such
as a periampullary diverticulum or previous surgery. Stones larger than 15 mm and those situated
intrahepatically or proximal to a biliary stricture
may be difficult to remove (Box 10.5). Adjuvant
techniques include mechanical lithotripsy, extracorporeal shockwave lithotripsy and chemical dissolu-
95,97,98
tion.
Although successful stone fragmentation
has been reported in up to 80% of patients, the major drawback is the need for multiple treatment sessions and at least one subsequent ERCP to extract
stone fragments.
The establishment of ERCP in the prelaparoscopic
era was based on the avoidance of an open exploration of the CBD, a procedure that was believed
Box10.5 • Difficult bile duct stones at ERCP
• Stones greater than 15 mm
• Intrahepatic stones
• Multiple stones
• Impacted stones
• Stone proximal to a biliary stricture
• Tortuous bile duct
• Disproportionate size of the bile duct stone
• Duodenal diverticulum
• Billroth II reconstruction
• Surgical duodenotomy
to have significant morbidity.99 ERCP was therefore
generally reserved for the high-risk surgical patients
but open cholecystectomy and exploration of the
CBD was reserved for the younger patient. In the
laparoscopic era, management strategies vary considerably and are based on local endoscopic and
laparoscopic resources and expertise.
ERCP stent insertion
In the 5% or less of situations where extraction of
CBD stones is incomplete or impossible, a nasobiliary tube or stent should be inserted to provide biliary decompression and prevent stone impaction of
the distal CBD (Fig. 10.8).
allow improvement of the patient's clinical condition until complete stone clearance can be achieved
by further endoscopic manoeuvres or subsequent
surgery. Temporary biliary endoprosthesis placement avoids accidental or intentional dislodgement
a
Figure10.8 • Multiple common bile duct stones
lying above a mid-common bile duct stricture and not
amenable to endoscopic extraction. Biliary drainage is
maintained with two endoscopically placed stents.
100
Such manoeuvres may
b
188
Gallstones
of the nasobiliary catheter by a confused or uncooperative patient. The stent may become blocked
after a few months, but bile drainage often continues around the stent, and the presence of the stent
alone may be sufficient to prevent stones from becoming impacted at the lower end of the CBD. In
the surgically unfit patient, a change of stent may
be required if jaundice recurs. Recurrent episodes
of cholangitis may result in secondary biliary cirrhosis in the long term, and careful consideration
of the patient's level of fitness must be made before
surgery is totally discounted.
Preoperative ERCP
For some, ERCP is the chosen method of preoperative CBD stone clearance, after imaging documentation of CBD stones with MRI or CT cholangiogram.
The advantage of this strategy is that duct clearance
preoperatively removes the dilemma as to how to
manage CBD stones found at operation. ERCP as
a tool to detect suspected stones without imaging
exposes a substantial number of patients to an unnecessary endoscopic intervention.
A randomised study has shown no significant ad-
vantage for patients treated by preoperative sphincterotomy as opposed to open cholecystectomy and
exploration of CBD alone.
101
Despite this, ERCP
and ES have become popular practice in the management of CBD stones, with an increased reliance
on ERCP and a reluctance among surgeons to perform surgical exploration of the CBD.
102
Cholecystectomy should routinely follow clearance of the CBD except in those considered too frail
or unfit for general anaesthetic. It can be expected
that if the gallbladder is left intact following ERCP
and ES, up to 47% of patients will develop at least
one recurrent biliary event, with many requiring
cholecystectomy.
86
Intraoperative ERCP
There have been several reports over the years describing this technique with success but few centres
consider this the most appropriate use of resources.
103
Postoperative ERCP
If ductal stones are not suspected preoperatively,
their presence can be determined at laparoscopic
cholecystectomy by IOC. CBD stones identified in
this way could be referred for postoperative endoscopic clearance if the surgeon was unable to explore
the duct. Such a policy would reduce dramatically
the number of ERCPs undertaken by a policy of
routine or selective preoperative ERCP. This would
leave only a small proportion of patients in whom
stones could not be cleared by ERCP, requiring a
second operation.
aroscopic exploration of the CBD, ERCP should be
104
If the surgeon is trained in lap-
reserved for the few patients in whom laparoscopic
ductal clearance fails. A recent randomised trial
lends some evidence that this approach is safe and
represents an effective management plan.
88
At the present time, the precise role of ERCP remains to be defined but is likely to be dictated by
local expertise and practice (see ‘Laparoscopic choledochotomy’ above). A number of acceptable algorithms have been proposed to manage laparoscopic
cholecystectomy patients suspected of harbouring
CBD stones.
There is also an argument for leaving small stones
(<5 mm) found intraoperatively. On follow-up for
up to 33 months in a small group of patients, 29%
in this category developed symptoms, but were
safely managed with ERCP.
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Laparoscopic exploration of the CBD versus preoperative or postoperative ERCP
At present, the array of management strategies for
common duct stones requires data to guide us, with
the techniques employed depending on local circumstances. In hospitals with ready access to ERCP,
a surgeon may see little need for ascending the
learning curve of laparoscopic CBD exploration,
whereas those units with less ready access to ERCP
see many attractions in dealing with common duct
stones by laparoscopic means.
Preoperative ERCP and laparoscopic clearance of
the CBD have been shown to be equivalent in overall outcomes.83 However, those patients whose ductal stones were cleared transcystically experienced a
far shorter hospital stay.
Postoperative ERCP clearance in a small singlesurgeon study showed equivalent overall outcome
to laparoscopic CBD clearance.84 However, the
number of choledochotomies was small and the retained stone rate high. Placement of biliary stents at
the time of operation may improve the success of
postoperative ERCP and stone clearance.
With experience, the majority of CBD stones can
be treated at the time of surgery provided a flexible
approach is employed.85 No single technique will be
applicable to the management of all stones. In general, if the stones are few in number, small (<1 cm) in
size, situated in the common duct or distal to cystic
duct entry, then transcystic exploration has a high
chance of success. If the stone or stones are large
and numerous, or if the stones are situated in the
common hepatic duct or intrahepatic biliary tree,
a choledochotomy and exploration with the larger
5-mm choledochoscope is the preferred option.
Intraoperative stone fragmentation remains an option for stones found at operation that are unable
to be dislodged at laparoscopic or open surgery,
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