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Laparoscopic common bile duct exploration: transcystic approach
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摘要
The description of the laparoscopic common bile duct exploration: transcystic approach covers all aspects of the surgical procedure used for the management of common bile duct stones.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration and exposure, dissection, intraoperative cholangiography, laparoscopic ultrasonography, dilatation, stone extraction, cholecystectomy.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration and exposure, dissection, intraoperative cholangiography, laparoscopic ultrasonography, dilatation, stone extraction, cholecystectomy.
Consequently, this operating technique is well standardized for the management of this condition.
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媒體類型
 刊物
2003-09
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普通的
最愛
 音訊
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數位出版
WeBSurg.com, Sept 2003;3(09).
URL: http://www.websurg.com/doi-ot02en014a.htm
URL: http://www.websurg.com/doi-ot02en014a.htm
Laparoscopic common bile duct exploration: transcystic approach
1. Introduction
Since the original description by Courvoisier of common bile duct (CBD) surgery in 1889 (Courvoisier, 1890), this field has changed dramatically. Introduction of laparoscopic cholecystectomy in 1989 (Dubois et al., 1989) has accelerated these changes, and as a logical extension to this the next step was the exploration of the CBD. Several reports from experienced groups have demonstrated the efficacy, safety and cost-effectiveness of laparoscopic techniques to deal with CBD stones (Berthou et al., 1997; Cuschieri et al., 1996; Cuschieri et al., 1999; Tranter and Thompson, 2002; Vecchio and MacFadyen, 2002). Two laparoscopic techniques to clear the common bile duct of stones exist. These are the transcystic and the choledochotomy approaches. Laparoscopic exploration is widely used in different centers across the world, but has not yet become standard treatment. These techniques enable appropriate patients to undergo complete management of their biliary tract disease with one invasive procedure. A frequently used alternative to surgery for choledocholithiasis is endoscopic retrograde cholangio-pancreatography (ERCP). This technique is extensively used, but carries a risk of pancreatitis, hemorrhage and duodenal perforation. In addition to this, there is the increased cost of patient management since these patients will have required surgical intervention (cholecystectomy), before or after the ERCP.
Once choledocholithiasis is confirmed by intraoperative cholangiogram or ultrasound, the surgical decision will depend upon the location, number and size of stones, anatomy, equipment, and surgeon expertise and preference. If a decision is made to proceed with the transcystic approach, the cystic duct will need to be incised and possibly dilated before the stones can be removed by one of a number of options. Confirmation of stone clearance is necessary once the procedure is completed. If this procedure is unsuccessful, one can proceed with other options such as CBD exploration, open surgery or postoperative ERCP.
In a review by Vecchio and MacFadyen (2002), the most common laparoscopic approach for common bile duct stones was the transcystic approach.
Note: sections 1 to 11 are identical for all chapters on laparoscopic bile duct exploration.
In memoriam of B Malassagne who drafted the first version of this chapter.
2. Biliary anatomy
• Common bile duct
The right and left hepatic ducts collect bile from the liver; they merge to form the hepatic duct, which passes downward in the free edge of the lesser omentum, where it is usually joined at an acute angle by the cystic duct, to form the common bile duct (CBD). It passes behind the superior portion of the duodenum, in front of the portal vein, and to the right of the hepatic artery; it then runs in a groove near the right border of the posterior surface of the head of the pancreas. It usually unites with the pancreatic duct and opens into the duodenum by a common orifice at the ampulla of Vater (major duodenal papilla).1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Variations/extrahepatic ducts 1
• Principles
A sound, working knowledge of the anatomic variations will facilitate intraoperative identification of the various ductal structures. Complete identification of the structures of Calot’s triangle before any duct is opened or divided is mandatory to safeguard against potentially serious complications of this surgical procedure.• Variation 1
Cystic duct insertion of the right lateral (posterior) segment• Variation 2
Duct of Luschka• Variation 3
Duct of Luschka• Variation 4
Direct drainage into the gallbladder of the right lateral (posterior) segments and right paramedian (anterior) segments• Variations/extrahepatic ducts 2
• Variation 5
Gallbladder insertion of accessory right hepatic duct• Variation 6
Congenital absence of a cystic duct• Variation 7
Low union with common hepatic duct• Cystic duct
The cystic duct is around 4 cm long, runs downward and medially to join the hepatic duct to form the common bile duct. The mucous membrane lining its interior is thrown into a series of crescentic folds, from five to twelve in number (cystic valves). The cystic duct usually enters the common bile duct at an acute angle. However, the cystic duct may run parallel to the common hepatic duct for a variable distance before joining it on its right side or pass anterior or posterior to the common hepatic duct before joining it on its left side. In addition, the cystic duct may join either the right hepatic duct or a segmental branch of the right hepatic duct. An accessory hepatic duct or cholecystohepatic duct (duct of Luschka) may also enter the gallbladder through the gallbladder fossa and if encountered during a cholecystectomy should be ligated to prevent a biliary fistula.
• Variation 1
Anterior crossing, left insertion• Variation 2
Posterior crossing, left insertion• Variation 3
Lower insertion3. Vascular anatomy
• Hepatic artery
From the celiac trunk, the common hepatic artery passes anteriorly and to the right, to the upper margin of the first part of the duodenum, forming the lower boundary of the foramen of Winslow. It then crosses the portal vein anteriorly and ascends between the layers of the lesser omentum to the porta hepatis as the hepatic artery. Here it divides into two branches, right and left hepatic arteries, which each supply the corresponding lobe of the liver. The hepatic artery, in its course along the free edge of the lesser omentum, is in relation with the common bile duct and portal vein, with the duct lying to the lateral to the artery, and the vein behind (portal triad). The left hepatic artery may have its origin from the left gastric artery in about 15-20% of the patients. The right hepatic artery may originate from the superior mesenteric artery in up to 20% of cases.1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Cystic artery
The cystic artery is usually a branch of the right hepatic but may also originate from the left hepatic, common hepatic, gastroduodenal, or superior mesenteric arteries. The cystic artery is usually located within the borders of Calot’s triangle (hepatic duct, cystic and lower border of liver). It usually enters this space by passing from behind the hepatic duct but there are a number of variations. The cystic artery divides into anterior and posterior branches before entering the gallbladder. 1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Variation 1
Double cystic artery; one posterior-inferior and one anterior-superior to the cystic duct• Variation 2
Double cystic artery; both superior to the cystic duct high in Calot’s triangle • Variation 3
Cystic artery originating from the proper hepatic artery• Variation 4
Cystic artery originating from a normal left hepatic artery, high in Calot’s triangle• Variation 5
Cystic artery originating from the celiac trunk, anterior-superior to the cystic duct• Biliary tract blood supply
The blood supply to the extrahepatic biliary tract originates distally from the gastroduodenal, retroduodenal, and posterior superior pancreaticoduodenal arteries and proximally from the right hepatic and cystic arteries. These arteries supply the common bile duct and common hepatic duct through branches that usually run parallel to the duct in the 3 and the 9 o\'clock positions.1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Portal vein
The portal vein is about 8 cm long, and is formed at the level of the second lumbar vertebra in front of the inferior vena cava and behind the neck of the pancreas by the union of the superior mesenteric and splenic veins. It ascends in the free edge of the lesser omentum behind the biliary tract and hepatic artery. It divides into a right and a left branch, which accompany the corresponding branches of the hepatic artery into the substance of the liver. It is accompanied by a rich lymphatic plexus. The right branch of the portal vein enters the right lobe of the liver, but before doing so it generally receives the cystic vein.1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
4. Operating room set-up
• European technique
• Patient
The patient is positioned:- supine;
- with the left arm placed at 90°;
- the right arm alongside the body;
- the legs apart;
- reverse Trendelenburg.
• Team
1. The surgeon stands between the patient’s legs.2. The first assistant is on the patient’s left side.
3. The second assistant’s position varies depending on the team’s preferences, most often to the patient’s right, facing the first assistant.
• Equipment
1. Radiological equipment (portable X-ray unit or portable C-arm fluoroscope, laparoscopic ultrasound)2. Laparoscopic unit
3. Anesthetic unit
4. Laparoscopic unit for choledochoscopy
5. Instrument table
6. Electrocautery
7. Operating table
• American technique
• Patient
The patient is positioned:- supine;
- with the left arm placed at 90°;
- the right arm alongside the body;
- the legs together;
- reverse Trendelenburg;
- lateral tilt to patient’s left.
• Team
The surgeon operates from the left side of the patient with the camera person by his side and the assistant and scrub nurse on the other side of the operating table.1. The surgeon is on the patient’s left side.
2. The first assistant is on the patient’s right side, facing the surgeon.
3. The second assistant is on the patient’s left side, next to the surgeon.
• Equipment
1. Radiological equipment (portable X-ray unit or portable C-arm fluoroscope, laparoscopic ultrasound)2. Laparoscopic unit
3. Anesthetic unit
4. Laparoscopic unit for choledochoscopy
5. Instrument table
6. Electrocautery
7. Operating table
5. Choice/technique
Different groups have reported success with both the transcystic, and the choledochotomy techniques. The following table (adapted from Cameron, 2001) gives appropriate indications for the two techniques. For those surgeons with significant laparoscopic experience, some of the contraindications may be relative. TA = Transcystic Approach
Ch = Choledochotomy
* to insertion of cystic duct
NR = Not Recommended
6. Trocar placement
• European technique
• Principles
In addition to the 4 trocars usually used for cholecystectomies, a fifth trocar (large enough for the choledochoscope) may be required. It is placed in the right subcostal area in the axis of the cystic duct, halfway between the xiphoid and the right subcostal trocars. • Optical
The optical trocar is positioned in the umbilical area. In our practice, we use a 0 degree scope, but a 30 degree one may sometimes be useful.• Operating
The operating trocars are positioned in the right and left hypochondrium. The graspers, scissors, hook, clip applier or dissection devices are introduced through these trocars.• Retractor
The retractor trocar is positioned in the epigastric area. In addition to the retracting instruments, a suction-irrigation device can also be introduced through this trocar.• Choledochoscopy
A fifth trocar may be introduced if needed to perform choledochoscopy. To avoid damaging the choledochoscope, a trocar with no valve or a retractable valve is ideal. This trocar must be long enough to allow the tip of the choledochoscope to enter the cystic duct lumen without having to handle it with a grasper.• American technique
• Principles
Trocars are placed in a similar fashion to laparoscopic cholecystectomy by American technique. Four trocars are commonly used. A fifth trocar may be placed just over the area of the gallbladder for introduction of instrumentation or the choledochoscope into the cystic duct.• Optical
The optical trocar is positioned in the umbilical area. In our practice, we use a 0 degree scope, but a 30 degree one may sometimes be useful.• Operating
The operating trocars are positioned in the epigastrium and right subcostal area on the mid-clavicular line. The graspers, scissors, hook, clip applier or dissection devices are introduced through these trocars.• Retractor
The retractor trocar is positioned in the right subcostal area on the anterior axillary line. • Choledochoscopy
A fifth trocar may be introduced if needed to perform cholangioscopy. To avoid damaging the choledochoscope, a trocar with no valve or a retractable valve is ideal. This trocar must be long enough to allow the tip of the choledochoscope to enter the cystic duct lumen without having to handle it with a grasper.7. Instrumentation
• Choledochoscope
The choledochoscope used in the transcystic approach has a small outer caliber (<= 3.2 mm). The dimensions of the operating channel must be >= 1.1 mm (in order to be able to introduce a Dormia basket while maintaining the irrigation flow). The choledochoscope should have a maneuverable tip, but with a certain degree of rigidity.• Ultrasound
Ultrasound has been used successfully in open surgery for many years. Since the introduction of laparoscopic ultrasound probes, this technology has also been used for evaluation of abdominal pathology during minimally invasive procedures. With the loss of touch and stereoscopic vision during laparoscopy, such technologies become an important source of additional information. Ultrasound can be used for evaluation of the biliary anatomy and to evaluate the presence of stones. Several probes with or without flexible tips and with different degrees of motion are available on the market.• Extraction devices
The Dormia baskets used must be of small caliber (<=1 mm) to allow for irrigation of the CBD during manipulation. Since the operating channel of the choledochoscope measures 1.1 mm, it is ideal to use 0.8 mm Dormia baskets although the Dormia basket can be passed alongside the scope (see video).1. Dormia basket
2. Suction-irrigation device
3. Atraumatic grasper
• Dilators
Semi-rigid dilators are used:- bougies or flexible atraumatic dilators;
- sequential bougie catheters;
- balloon dilatation catheters – these can also be used to extract stones.
• Drains
A transcystic drain can be left in situ where there is concern about postoperative CBD obstruction from inflammation, edema or retained stones as a “safety valve”. It can also be used postoperatively for imaging.8. Exploration and exposure
• Exposure/right subhepatic area
• Principles
Routine abdominal exploration is carried out after introduction of the laparoscope. Once done, we focus our attention to the biliary tree and gallbladder. An initial important step in bile duct surgery is adequate exposure of the subhepatic area. Techniques that may aid with this task include:• Suspension of the liver
The liver is lifted by suspension of the ligamentum teres with the aid of a transcutaneous suture. • Gravity
The patient is placed in steep reverse Trendelenburg position with a slight tilt to the left, facilitating the descent of the organs towards the pelvis and left side.• Retraction
The duodenum is retracted caudally with the use of a retractor. The gallbladder infundibulum is retracted upward and laterally.• Exposure of Calot’s triangle
To ensure safe dissection, perfect exposure of the anterior surface of Calot’s triangle is essential. Once any adhesions to the gallbladder are freed, Calot’s triangle is stretched open by retracting the fundus of the gallbladder superiorly and stretching the cystic duct laterally (to the right) by retracting laterally on the infundibulum of the gallbladder (Hartman’s pouch). This principle of exposure is used in both the European and American techniques but the ports used for retraction differ.9. Dissection
• Dissection of Calot’s triangle
The aim of this step is to isolate the biliary and vascular elements constituting Calot’s triangle.The dissection is begun in close proximity of the gallbladder, at the junction between the infundibulum and the cystic duct.
The peritoneum covering the neck of the gallbladder is incised posteriorly and anteriorly.
At this point, skeletalization of the elements of the cystic pedicle is performed. The cystic duct, and the cystic artery respectively, are fully exposed (for greater detail see chapter on laparoscopic cholecystectomy).
• Clip application
After identifying the cystic artery and cystic duct, the artery is clipped proximally and distally. The cystic duct is then clipped close to its junction with the gallbladder. If indicated, transcystic cholangiography or laparoscopic ultrasound follows to evaluate the local anatomy and the presence of stones. 10. Intraoperative cholangiography
• Goals
- to assess the anatomy of the biliary tract (anatomic variations and size of the CBD);- to determine the location, size and number of the calculi.
Static simple X-rays have been used in the past to assess the biliary tract but are inferior to dynamic fluoroscopy, which allows real-time assessment of the biliary tract anatomy. Fluoroscopy has been demonstrated to be faster to perform and more accurate than static IOC (Jones et al., 1995; Berci, 1995).
• Technique
• Cystic duct incision
The cystic duct is partially transected on its anterior surface 1 cm from the junction with the CBD. This location is chosen in order to avoid problems in inserting the cholangiocatheter due to valvulae or plications of the cystic duct. It also facilitates easy closure of the cystic duct stump without risk of injury to the CBD. Thus the cystic duct junction with the CBD must be identified. It is important not to fully transect the cystic duct as traction on the gallbladder helps to keep the duct well exposed.• Position/OP table
The operating table is placed into a flat position (i.e. taken out of reverse Trendelenburg and left tilt) with a slight right tilt to displace the CBD anteriorly.• Catheter introduction
The cholangiocatheter is brought to the incision of the cystic duct using a rigid introducer, either percutaneously or through the right subcostal trocar (there are also soft catheters and special cystic clamps that can also be used for cholangiography). The probe is inserted 1 to 3 cm and held in place with a clip or a grasper. We recommend using a rigid tip probe for this part of the procedure to avoid occlusion of the probe by the clip.
• Contrast injection
Cholangiography is performed in three steps:1. A few milliliters of diluted contrast (50% dilution) are injected into the bile ducts under radiographic guidance. It is essential to ensure that no air bubbles are in the injection set because air bubbles in the CBD can be confused with stones. If static pictures are being taken the first is taken now to detect stones in the CBD.
2. The dye injection is continued until a complete cholangiogram is obtained. The Trendelenburg position may facilitate the opacification of the intrahepatic bile ducts. A second static picture is taken at this point.
3. The passage of dye into the duodenum under low pressure should be confirmed by a third radiograph.
If there is inadequate visualization of the entire common bile duct during cholangiography, gentle pressure can be placed with an instrument over the distal part of the CBD to encourage adequate filling and delineation. If fluoroscopy is being used then images can be obtained dynamically while injecting contrast.
• Catheter removal
The cholangiocatheter is removed once the cholangiogram is finished, and if no stones are found the cystic duct is closed and a completion cholecystectomy performed.The presence of stones in the CBD is suspected when the radiograph demonstrates:
- radiolucent defect(s);
- a crescent-shaped blockage of the contrast;
- dilatation of the bile ducts;
- the absence of passage of the contrast into the duodenum.
The choice to perform a transcystic approach rather than a choledochotomy will depend upon the precise findings (see indications/contraindications).
11. Laparoscopic ultrasonography
Ultrasound (US) examination of the bile duct during cholecystectomy compares well with operative cholangiography. Tranter and Thompson (2003) describe their results on intraoperative ultrasound versus intraoperative cholangiography (IOC). US demonstrated the biliary tree better than intraoperative cholangiography, and proved to be more sensitive and specific in the diagnosis of bile duct stones.The use of intraoperative ultrasonography (IOUS) also saves the patient from ionizing radiation, and may be possible where IOC has failed. It does however require special skills of interpretation in which few surgeons have been trained (Thompson et al., 1998; Falcone et al., 1999).
12. Dilatation
• Dilatation
Before dilatation of the cystic duct, while the catheter is still in place, attempts may be made to use it to flush the stones from the CBD. For this, 1 to 2 mg intravenous glucagon can be given to the patient to relax the sphincter of hepatopancreatic ampulla (Oddi’s sphincter) and permit the flushing of small stones into the duodenum. Hunter and Soper (1992) reported that cystic duct dilatation is unnecessary in >50% of cases as it is generally dilated to the size of the stone that passed into the CBD.• Techniques
• Forceps
It is possible, and in some cases preferable, to dilate the cystic duct with the help of an atraumatic right angulated forceps.• Balloon catheter
Dilatation of the cystic duct can be performed using a balloon catheter (Fogarty catheter used in angioplasty) inflated to 8 atmospheres of pressure over several minutes. The disadvantage of this technique is that it can cause tearing of the cystic duct.• Flexible dilators
The dilatation of the cystic duct is achieved using flexible atraumatic dilators introduced through the subxiphoid trocar. The duct is dilated to the size of the largest stone, generally no greater than 16 French (a maximum diameter of 5 to 7 mm). These dilators can seriously damage the cystic and CBD if not used with caution.13. Stone extraction
• Techniques
Once adequate cystic duct diameter is achieved, the stones can be removed by several means either under fluoroscopic or choledochoscopic guidance or as blind procedure. The ultimate goal is to completely clear the biliary tract of stones, avoiding bile duct injuries. To prevent stones from escaping into the abdominal cavity or into the lesser sac of the peritoneum, a gauze pad or an endoscopic extraction bag can be placed behind the hepatoduodenal ligament and below the neck of the gallbladder to catch stones as they appear from the cystic duct.• Blind extraction
• With a grasper
Stones that are easily accessible or visible through the cystic duct incision are extracted with atraumatic graspers. Stones can also be pushed out by exerting pressure with the graspers on the surrounding cystic wall.• With a Fogarty catheter
The catheter is passed into the CBD and beyond the stone. It is then inflated to occlude the lumen and gently withdrawn bringing any stone up into the cystic duct stump. It can be useful to dislodge impacted stones. • With a Dormia basket
The basket is introduced into the cystic duct. It is then opened and the catheter is moved around slowly until the stone can be felt and pushed into the basket to be removed. • Extraction under visual guidance
• With fluoroscopy
The Dormia basket is introduced into the CBD under fluoroscopic guidance. The stone entrapment and extraction can also be visualized fluoroscopically. • With choledochoscopy
Stone extraction under endoscopic guidance includes the following steps:- introduction of the choledochoscope and visualization of the stone (s);
- introduction of the Dormia basket into the CBD through the operating channel (or alongside the choledochoscope). The stone is retrieved by the Dormia basket and securely held against the tip of the endoscope.
The choledochoscope is withdrawn with the Dormia basket under continual view.
• Stone clearance/difficult stones
It is mandatory to confirm that the CBD has been completely cleared. This may be done with the choledochoscope, cholangiography or ultrasound. The CBD is explored to the papilla. Above the cystic duct-CBD junction, endoscopic exploration is difficult. In cases where there is suspicion of stones located proximally, cholangiography should be performed.
When direct extraction through the cystic duct is impossible due to the size of the stone, it may be necessary to make a longitudinal incision along the cystic duct on the protrusion of the stone. The stone can then be extracted using an atraumatic grasper (see video).
14. Cholecystectomy
• Closure of the cystic duct
A simple closure of the cystic duct using ligature, suture or clipping techniques should be done without exerting excessive traction on the cystic duct. Completion of cystic duct transection should only be done after the proximal end has been closed.In cases of a dilated cystic duct, the length of a clip may be insufficient and it may be necessary to resort to a ligature (preformed loop or intracorporeal suture) in order to ensure that the cystic duct has no leaks.
• Closure over a transcystic drain
A transcystic drain can be placed to prevent excessive pressure in the CBD when there is concern about the CBD clearance or in cases of significant inflammation/edema of the papilla. The drain is held with an absorbable ligature to the cystic duct stump.• Cholecystectomy
After closure of the cystic duct a retrograde cholecystectomy is performed, as described in the cholecystectomy chapter. It is probably better to perform cholecystectomy without division of the cystic duct to keep a good exposure of the CBD prior placement of T-tube or transcystic drain to avoid its displacement during cholecystectomy.15. Postop management
In the absence of biliary drainage:Oral intake is restarted postoperatively as soon as the patient recovers form anesthesia and advance as tolerated.
Patients stay at least overnight for observation. If no drain was placed during surgery and they are doing well, they are discharged the next day.
In the presence of biliary drainage:
Oral intake is restarted postoperatively as soon as the patient recovers form anesthesia and advance as tolerated.
Cholangiography is performed on the first or second postoperative day. If follow-up is normal, the transcystic drain is clamped and removed after 3 or 4 weeks. Patients are instructed on drain care. In case of poor drainage into the duodenum without residual stones, the drain is left open for 10 to 15 days. Another cholangiography is then done before removal.
For residual stone(s), the drain is left open until, either, there is spontaneous clearance of the CBD (50% of cases) or until an endoscopic sphincterotomy can be performed.
Complications
The morbidity of laparoscopic common bile duct exploration (LCBDE) ranges between 0 and 29.1%. Bile leak is the most common complication after LCBDE and accounts for 40% of all complications (Vecchio and MacFadyen, 2002). Although re-operation or ERCP is required in some cases, most leaks are self-limiting and can be treated successfully by percutaneous drainage.
The most worrying complications related to the transcystic approach is CBD injury and it is essential that such injuries are identified immediately as late presentation is associated with poorer outcome.
16. Conclusions
Transcystic common bile duct exploration in conjunction with laparoscopic cholecystectomy will clear the CBD in more than 75% of patients. It may be easier to perform than a choledochotomy, particularly in those patients with a small diameter CBD or intense inflammation. In a review by Vecchio and MacFadyen (2002), the most common laparoscopic approach to the CBD was the transcystic route. Some surgeons perform a laparoscopic choledochotomy only when the transcystic approach has failed. The location of stones in the proximal common bile duct, acute angulation of the cystic duct-CBD junction, cystic valves or tortuosity of the cystic duct, low or abnormal insertion of the cystic duct into the CBD, or CBD stones larger than 6-7 mm in diameter are some of the common factors that will prevent the use of this technique to approach CBD stones.In experienced hands laparoscopic common bile duct exploration is a cost-effective and perhaps the safest method to treat common bile duct stones.
17. Reference
Ahmed I, Pradhan C, Beckingham IJ, Brooks AJ, Rowlands BJ, Lobo DN. Is a T-tube necessary after common bile duct exploration? World J Surg 2008;32:1485-8.
Courvoisier LG. Casuistisch-statistische Beiträge zur Pathologie und Chirurgie der Gallenwege
Leipzig, Vogel, 1890, pp. 57-58.
Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999;13:952-7.
Decker G, Borie F, Millat B, Berthou JC, Deleuze A, Drouard F, et al. One hundred laparoscopic choledochotomies with primary closure of the common bile duct. Surg Endosc 2003;17:12-8.
Faisal Hanif, Zubir Ahmed, Abdel Samie A, Nassar AHM. Laparoscopic transcystic bile duct exploration: the treatment of first choice for common bile duct stones. Surg Endosc 2010. Epub ahead of print.
Falcone RA, Jr., Fegelman EJ, Nussbaum MS, Brown DL, Bebbe TM, Merhar GL, et al. A prospective comparison of laparoscopic ultrasound vs intraoperative cholangiogram during laparoscopic cholecystectomy. Surg Endosc 1999;13:784-8.
Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg 2009;7:338-46.
Gurusamy KS, Samraj K. Primary closure versus T-tube drainage after open common bile duct exploration. Cochrane Database Syst Rev 2007;(1):CD005640.
Ha JP, Tang CN, Siu WT, Chau CH, Li MK. Primary closure versus T-tube drainage after laparoscopic choledochotomy for common bile duct stones. Hepatogastroenterology 2004;51:1605-8.
Jameel M, Darmas B, Baker AL. Trend towards primary closure following laparoscopic exploration of the common bile duct. Ann R Coll Surg Engl 2008;90:29-35.
Kharbutli B, Velanovich V. Management of preoperatively suspected choledocholithiasis: a decision analysis. J Gastrointest Surg 2008;12:1973-80.
Kumar P, Orizu M, Leung E. Laparoscopic T-tube placement after common bile duct exploration: a simple technique. Surg Laparosc Endosc Percutan Tech 2009;19:e36-7.
Pérez G, Escalona A, Jarufe N, Ibáñez L, Viviani P, García C, Benavides C, Salvadó J. Prospective randomized study of T-tube versus biliary stent for common bile duct decompression after open choledochotomy. World J Surg 2005;29:869-72.
Phillips EH, Toouli J, Pitt HA, Soper NJ. Treatment of common bile duct stones discovered during cholecystectomy. J Gastrointest Surg 2008;12:624-8.
Shojaiefard A, Esmaeilzadeh M, Ghafouri A, Mehrabi A. Various techniques for the surgical treatment of common bile duct stones: a meta review. Gastroenterol Res Pract 2009;2009:840208.
Tang CN, Tai CK, Ha JP, Tsui KK, Wong DC, Li MK. Antegrade biliary stenting versus T-tube drainage after laparoscopic choledochotomy--a comparative cohort study. Hepatogastroenterology 2006;53:330-4.
Tokumura H, Umezawa A, Cao H, Sakamoto N, Imaoka Y, Ouchi A, Yamamoto K. Laparoscopic management of common bile duct stones: transcystic approach and choledochotomy. J Hepatobiliary Pancreat Surg 2002;9:206-12.
Tranter SE, Thompson MH. A prospective single-blinded controlled study comparing laparoscopic ultrasound of the common bile duct with operative cholangiography. Surg Endosc 2003;17:216-9.
Wu JS, Soper NJ. Comparison of laparoscopic choledochotomy closure techniques. Surg Endosc 2002;14:14.
Zhang WJ, Xu GF, Wu GZ, Li JM, Dong ZT, Mo XD. Laparoscopic exploration of common bile duct with primary closure versus T-tube drainage: a randomized clinical trial. J Surg Res 2009;157:e1-5.