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Abstract
This study was carried out on thirty patients with gallstones and small secondary common bile duct stones less than 10 millimeters in diameter. The aim of this study was to assess the role and feasibility of laparoscopic common bile duct exploration through the cystic duct for clearance of these small stones.
There were twenty females (66.7 %) and ten males (33.3 %), their age ranged from 18 to 63 years with a mean age of 41.7 ± 13.3 years. All cases were subjected to thorough history taking and complete clinical examination. Laboratory investigations (aspartate aminotransferase, alanine aminotransferase, total and direct bilirubin, alkaline phosphatase and gamma-glutamyl transferase) followed by ultrasonography, computed tomography (CT) of the abdomen or magnetic resonance cholangiopancreatography (MRCP) when needed, were then performed.
Patients with gallstones and small secondary CBD stones less than 10 mm as confirmed by ultrasonography and/or MRCP were included in this study. Patients with large stones, suspicion of other biliary pathology, extremes of age or unfitness for laparoscopic surgery were excluded.
Patients were subjected to intraoperative cholangiography (IOC) and/or choledochoscopy. In IOC; 4 cases (13.3%) had a single CBD stone, 4 cases (13.3%) had two CBD stones, 3 cases (10%) had 3 CBD stones, 2 cases had 5 CBD stones and in 5 cases, the CBD contained more than 5 stones.
Different transcystic techniques (step 1) were employed to clear the CBD of stones. These techniques included saline irrigation, fluoroscopiuc wire basket stone retrieval, choledochoscopic basket stone extraction, balloon extraction, ampullary balloon dilatation and antegrade sphincterotomy. If these methods failed, step 2 (Rendez-vous technique or intraoperative ERCP) was tried. If this also failed, step 3 (laparoscopic choledochotomy with T-tube insertion) was performed. After failure of all laparoscopic steps, open CBD exploration was the last choice. IOC and/or choledochoscopy were the endpoint for assessment of complete CBD clearance of stones.
The overall success rate of laparoscopic techniques was 87% with complete CBD clearance of stones. The transcystic approach was successful in 18 cases (60%), the Rendez-vous technique and intraoperative ERCP succeeded in further 5 cases, raising the success rate to 76.7%. Laparoscopic choledochotomy was performed in 3 more cases. However, 3 cases (10%) were converted to open surgical treatment after failure of all laparoscopic techniques. In one case, small stone was left to pass spontaneously.
Saline irrigation or stone pushing with a tube catheter was tried in all cases and was successful alone in 4 cases (13.3%) in flushing stone(s) out of the CBD to the duodenum, fluoroscopic wire basket stone retrieval in 13 (43.3%) cases with a success rate of 42.8%, choledochoscopic basket stone extraction in 7 (23.3%) with a success rate of 71.5%, ampullary balloon dilatation in 8 (26.7%) with a success rate of 37.5%, antegrade sphincterotomy in 5 (16.6%) with a success rate of 60% and fogarty balloon extraction in 5 (16.6%) cases with a 20% success rate.
The mean operative time of transcystic approach (n = 19) was 143.3 minutes ± 35.4 (median 150 minutes, range 90 to 180 minutes). The median operative time in step 2 (Rendez-vous technique or intraoperative ERCP) n=5 was 174 minutes (from 150 to 210 minutes).
The mean hospital stay was 4.1 days ± 3.63 (median 3 days, range from one to 20 days). In successful transcystic cases (n = 18), the mean hospital stay was 2.8 ± 1.24 days (median 3 days, range from one to 6 days), while in failed cases it was much longer 6 ± 5 days (median 4 days, range one to 20 days) .
Peristalsis was audible and patients started oral fluid intake in the same day of surgery in 12 cases (40%), oral fluid intake commenced on the first postoperative day in 11 patients (36.7%). The tube drain was left for one day in 20 cases (66.7%).
Complications occurred in 12 cases with a morbidity rate of 40 % (4 operative, 5 major and 14 minor complications). There were two cases of retained stones. There was no 30 days mortality .