Laparoscopic exploration of bile ducts in patients with calculosis. Indications, methods and first results.

INTRODUCTION: In the last few years there has been a resurgence of laparoscopic exploration of the common bile duct as an alternative to endoscopic retrograde cholangiopancreatography (ERCP), the primary method for diagnosis and treatment of biliary tract calculosis.

AIM: The aim of this study was to clarify the indications and methods for performing laparoscopic bile duct exploration, based on our experience in the field and data from the literature.

PATIENTS AND METHODS: We recruited 12 patients who underwent laparoscopic exploration and stone extraction from the common bile duct (CBD) in the surgical ward of Kaspela Hospital, Plovdiv over the period January 2011 to January 2012. The diagnostic and therapeutic modalities used in the study included laboratory tests, ultrasound study, CT, ERCP, digital cholangiography, clamp and balloon stone extraction, primary suture and choledochoduodenostomy.

RESULTS: Stone extraction was successfully performed in 8 patients using the transcystic approach through an incision used in the cholangiography. The procedure failed in the remaining four patients and we used here 2-cm longitudinal choledochotomy. In two patients the control cholangiography following the extraction of stones demonstrated complete clearance of the biliary tree and free passage of contrast agent from bile duct to duodenum (patent ampulla of Vater). In these two patients we performed a primary closure of the choledochotomy with a single interrupted suture ("ideal choledochotomy"). In two patients from the choledochotomy group, the control cholangiography showed the presence of residual stones or fragments trapped above the sphincter of Oddi with no contrast medium in the duodenum. In these cases we completed this procedure with latero-lateral choledochoduodenostomy by Flërken. All patients had a smooth postoperative course with no recorded complications. The average hospital stay was 5 days.

CONCLUSIONS: Laparoscopic exploration of the biliary ducts in calculosis is an efficient, safe and reliable method to manage this serious complication of gall-stone disease in the hands of an experienced laparoscopic surgeon. The results of its application are comparable and in some cases even better than those of ERCP used as a therapeutic procedure as regards clearance of the CBD and the complications involved in these two procedures.