Laparoscopic Management of Biliary Stone Disease
Laparoscopic Management of Biliary Stone Disease
Various Technical Advances
The original Laparoscopic Cholecystectomy technique has undergone a vast
maturation process over the past decade. Various technical steps has been
modified and adapted to improve surgical performance and clinical outcome.
As a result, nowadays, most surgeons in the Western World can safely perform a Laparoscopic Cholecystectomy with a minimal conversion rate.
Routine operative cholangiography is recommended by
most laparoscopic authors in the United States. However, recent
reports demonstrate it does not significantly decrease the
rate of common bile duct injury in cases where the anatomy is
well-identified. Our recommendation is that routine intraoperative
cholangiography should be performed by inexperienced laparoscopic surgeons
and in cases where the anatomy is not well-defined.
1. A few years ago, our surgical team initiated a
study comparing a series of 400 laparoscopic cholecystectomies performed
with routine cholangiography versus 400 laparoscopic cholecystectomies
performed without routine operative cholangiography. There was no increase in morbidity, intra-operative injuries and/or ductal
biliary injuries. However, since this study involved experienced
laparoscopic surgeons, our guidelines were modified as follows: Routine
operative cholangiography is only recommended for neophytes and
inexperienced laparoscopic surgeons (less than 100 LapCholes) .
2. Routine operative cholangiography can and will
identify unsuspected common bile duct stones. Our surgical techniques have
been modified to try to identify patients with choledocholithiasis
preoperatively; therefore, this benefit does not justify the routine
performance of this test.
Patients With Choledocholithiasis
In order to achieve the level of Maximum Surgical
Performance with this procedure, patients at high risk of presenting with
Common Bile Duct Stones need to be identified pre-operatively. The simplest
methods to initially identify these patients are: 1) History and Physical
Examination, 2) Liver Function Studies, 3) Sonographic Findings.
Patients with a recent history of gallstone
pancreatitis, jaundice, or presenting with such symptoms are at a high risk
of having common bile duct pathology; the same is valid for patients with
altered liver function studies. The most accurate studies are the Serum
Transaminases (SGOT, SGPT). Elevations of these enzymes over 20% of
their normal values are significant. But patients with severe, acute
cholecystitis can occasionally generate such elevations. Also, extreme
elevations of these two enzymes could represent hepatocytes necrosis as seen
in hepatitis. The bilirubin level may also be elevated in certain patients
with acute cholecystitis, but elevations above 2.5 or 3.0 mg/dl could
identify a patient with choledocholithiasis. Finally, we find
the enzymes LDH and GGTP to have no real specific value in this clinical
It is interesting that in spite of our intensive
efforts to identify Common Bile Duct pathology preoperatively, missed Common
Bile Duct Stones are found in 1.92% of all patients. Of these patients 76%
will require additional surgical intervention (ERCP).
This technology is being used with increasing
frequency in our surgical service to identify patients with
choledocholithiasis. A GE Magnetic Resonance machine was used for all
studies. To date the specificity and accuracy of these studies in our
services is 98.2% for common bile duct stones over 1 mm in size.
Intra-operative cholangio-sonography is being used in
many medical centers to rule out common bile duct stone. Although this modality
was used on numerous occasions, we found it too time consuming to
be used on a routine basis.
or Subtotal Laparoscopic Cholecystectomy
In our never-ending quest of increasing surgical
performance, we meticulously analyzed when and why conversion occurred during the
performance of a laparoscopic cholecystectomy. Most of them occurred in patients with acute, severe and
gangrenous cholecystitis. Thus, we introduced the anterior-subtotal
laparoscopic cholecystectomy to be used ONLY in these clinical settings when
a standard laparoscopic Cholecystectomy could not be completed safely.
(Refer to Technique and Surgical Performance later in chapter).
Decreasing impact of the Laparoscopic CBD Exploration
Significant problems have impaired the growth
of Laparoscopic Common Bile Duct exploration. This technique is simply not
easy to perform and good results are only achieved by experienced operators. In addition, this procedure is hardware intensive and
the choledochoscopes are not as reliable as they are touted to be. For these
reasons it quickly become obvious to us, the indications for this procedure were
becoming more and more limited.
Our surgical team
promotes the use of Endoscopic Retrograde Cholangiography and Papillotomy.
When not feasible, a laparoscopic transcystic or via anterior choledochotomy
CBDE is performed. It should be mentioned that some critics claim there are
no studies available on the long term effects of endoscopic papillotomies
and that it represents a significant additional cost. Although, this
statement is correct, there are also no reports of long term adverse effects
of such procedures.
Since 1997, the number of laparoscopic common
bile duct explorations on our service has decreased sharply. We have totally
abandoned the trans-cystic common bile duct exploration previously
recommended in prior editions of this book. We now exclusively perform
laparoscopic anterior choledochotomy common bile duct exploration. Our sole
indication for a laparoscopic common bile duct exploration is a patient with
a large common bile duct (> 1.5 cm) who has undergone a previous
cholecystectomy and who has failed an ERC-ERCP retrieval.