الفهرس 
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Abstract
CBD stones are the most frequent complication of cholecystolithiasis and occur in 10%-15% of patients. They can be treated by either open, laparoscopic, or endoscopic means (shwan, 2014).
Laparoscopic surgery, also called minimally invasive surgery, bandaid surgery, keyhole surgery is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5–1.5 cm) as compared to the larger incisions needed in laparotomy. Keyhole surgery uses images displayed on TV monitors for magnification of the surgical elements (Stephen et al, 2004).
There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include reduced pain due to smaller incisions, less bleeding, shorter hospital stay and recovery time early return to normal life and decrease the postoperative adhesions (Jeon et al, 2009).
This study included 30 patients with clinical, biochemical or radiolological evidence of CBD stones who were prospectively admitted at Department of Surgery, Sohag University Hospital, from March 2011 to October 2014 and underwent elective simultaneous LC and LCBDE.
. Twenty eight patients (93.33%) were females and two were males (6.67%). The age ranged from 25 to 85 years.
The main presentation was biliary colic in 25 patients (83.33%), 16 of them (53.3%) had raise total and direct bilirubin (subclinical jaundice), and clinical jaundice was manifested in 5 patients (16.67%).
Laboratory investigations showed that total bilirubin ranged from 0.4-10 mg% (mean 2.54 ± 2.56, median 1.5), and direct bilirubin ranged from 0.04-8 mg% (mean1.66 ± 2.14, median 0.09).
Abdominal US was done in all patients (30 cases) and showed gallstones and dilatation of the CBD (≥ 8mm) in all of them, and CBD stones in 29 patients (96.6%). MRCP was done to the patient who had dilated CBD with no stones inside where it detected two stones in the CBD.
The diameter of the CBD ranged from 8-25 mm (mean 13.32 ± 3.16, median 13.00). The CBD stones were; single in 20 patients (66.67%), multiple in 8 patients (26.67%) and 2 stones in the remaining two patients (6.67%).The size of stones ranged from 5-16 mm (mean 8.42 ± 4.09, median 8.5).
Direct choledochotomy incision was the main approach in 27 patients (90%) (Including the 3 conversion cases), and transcystic approach in the remaining 3 patients (10%).
Clearance of the CBD was done mainly by flexible fiberoptic choledochoscope which was done in all patients through combination of wash, Dormia basket or balloon extraction. Milking alone failed to extract stone from the CBD.
The CBD was closed over suitable size latex T-tube (12-16 F) in 17 patients (56.66%) and primary closed without T tube in 10 patients (33.33%). Suturing was intracorporeal in all cases using polyglycolic acid 3/0 or 4/0 in an interrupted or continuous manner. In the 3 cases (10%) of transcystic approach the CD was closed using metallic clips.
The procedure was completed laparoscopically in 27 patients (90%) and only 3 cases were converted to open surgery (10%). The reasons for conversion were impacted stones in the distal end of CBD in 2 patients, one of them treated by transdudenal extraction of the stone and the other patient had 2 CBD stones which one stone was extracted laparosopically by Dormia basket and the other one was impacted so open surgery was done with extraction of the stone through the choledochotomy. In the 3rd case early significant bleeding in cirrhotic liver was occurred that jeopardized a safe laparoscopic approach.
The operative time (from skin incision to skin closures of trocars sites) was ranged from 90-210 minutes (mean 127 ± 22.77, median 120). The post operative hospital stay ranged from 5 to 15 days (mean 8.47 ± 2.36, median 9).
Postoperative complications occurred only in 3 patients (10%), all had biliary leakage after primary CBD closure. In 2 cases the leakage persisted for 4 and 5 days respectively and both were treated conservatively with no squeal. In the 3rd case who had both prolonged ileus for 4 days and biliary leakage more than 7 days with localized biliary collection in the pelvis. On ERCP all continuous stitches were found disrupted and ES with stent insertion was done. The leakage ceased and the pelvic collection was aspirated under US guide. The patient improved and had uneventful follow up on repeated US.
In conclusion LCBDE is a safe and technically feasible operation with good out come in managing choledocholithiasis, it include the numerous benefits of minimally invasive procedures, particularly less postoperative pain, hospital stay, more rapid recovery, and fewer complications when compared to open surgery. LCBDE during laparoscopic cholecystectomy solves 2 problems during the same anesthesia with high success rates approaching 90% or better and may be employed successfully.
The successful laparoscopic management of CBD stones depends on several factors including; surgical expertise which may be enhanced by training models in laparoscopic surgery, adequate equipment (Flexible choledocho-fiberscope, balloon catheter, basket forceps) and the biliary anatomy, and the number and size of CBD stones.
. The use of choledochoscope is of paramount important in the LCBDE. In addition to visualization and aiding extraction of the ductal stones, assurance of clearance of these stones, its deliberate and accurate use can lessen the need for preoperative MRCP (which expensive), and IOC (which is technically demanding) to our knowledge. This was a big series of LCBDE done in Upper Egypt area.
This study was a good competitor to endoscopic management of CBD stones in our institution and had obviously changed the attitude of managing of these problems.