Laparoscopic Common Bile Duct Exploration Mark J. Watson, MD, FACS,* Elizabeth C. Hamilton, MD,* and Daniel B. Jones, MD, FACS†

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s laparoscopic cholecystectomy became the standard approach for removal of the gallbladder, traditional common bile duct exploration has become an infrequent procedure. Most bile duct stones are now removed endoscopically when intervention is necessary. Techniques for the laparoscopic management of choledocholithiasis have been shown to be both safe and effective.1 Removal of stones from the common bile duct and hepatic ducts at the time of cholecystectomy has several advantages. Additional procedures, with their inherent costs and risks, can be avoided. The long-term sequelae of sphincterotomy also can be avoided with laparoscopic bile duct clearance.2,3

*University of Texas Southwestern Medical Center, Dallas, TX. †The Harvard Medical School, Chief, Section of Minimally Invasive Surgery, Beth Israel Deaconess Medical Center, Boston, MA. Address reprint requests to Daniel B. Jones, MD, FACS, Associate Professor, Harvard Medical School, Chief, Minimally Invasive Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. E-mail: [email protected]

1524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2004.12.005

The Transcystic Approach to Choledocholithiasis The primary laparoscopic approach to choledocholithiasis is via the cystic duct, therefore avoiding an incision in the common bile duct. Although intraoperative ultrasound will no doubt have an important and increasing role in the diagnosis and management of biliary tract disease, current transcystic management of bile duct stones requires competence in intraoperative cholangiography. Although controversy exists, many surgeons support the routine use of cholangiography during laparoscopic cholecystectomy.4-6 When the operating room staff and the surgeon are prepared, a cholangiogram performed under fluoroscopy adds minimal time to the procedure. This routine not only identifies the small percentage of unsuspected bile duct stones but also confidently defines the ductal anatomy for the completion of the procedure. Finally, surgeons performing routine cholangiography become experts at accessing the cystic duct, which is a prerequisite for transcystic bile duct exploration.

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Surgical Technique

Figure 1 After minimally invasive access to the abdominal cavity is achieved, laparoscopic ports are placed in a standard fashion for laparoscopic cholecystectomy (A, laparoscope; B and C, gall bladder retraction; D, working port; E, cholangiogram catheter).

Laparoscopic common bile duct exploration

Figure 2 Following dissection of the gallbladder neck and identification of the cystic duct, a surgical clip is placed on the cystic duct at the level of the gallbladder. A small cystic duct incision is fashioned just below the clip and its lumen is identified. A 5-Fr cholangiogram catheter is inserted percutaneously in a location that will facilitate further access to the cystic duct and common bile duct, if necessary. Most commonly, the catheter will be positioned close to the costal margin, between the mid epigastric and lateral ports. Once in the abdomen, the catheter is flushed with saline to clear it of air. A dissector is used to advance the catheter into the ductotomy and is then secured with a nonocclusive surgical clip.

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Figure 3 One-half-strength contrast is then injected through the catheter under fluoroscopy. This allows for rapid identification of biliary anatomy, filling defects within the bile ducts, and flow of contrast into the duodenum. (A) Normal cholangiogram demonstrating all pertinent anatomy. A normal cholangiogram will demonstrate the entire bile duct without filling defects. Unobstructed flow should be demonstrated into the duodenum, through the cystic duct/common bile duct junction and through the bifurcation of the hepatic duct with filling of the intrahepatic biliary radicals. If a normal cholangiogram is observed, the catheter can be removed, the cystic duct may be ligated, and the gallbladder can be removed in the usual fashion. (B) Abnormal cholangiogram and (C) Ultrasound demonstrating common bile duct stones (arrows). If stones are found in the common bile duct or hepatic ducts, a decision can be made then on how to proceed.

Laparoscopic common bile duct exploration

Figure 4 For common bile duct stones less than 3 to 4 mm in diameter, an attempt should be made to mechanically flush the stones from the duct. Intravenous administration of 1.0 mg of glucagon by the anesthesiologist can help relax the sphincter of Oddi and facilitate passage of small stones (A). Four minutes following glucagon administration, the cystic duct catheter is flushed with several 10-mL syringes of saline (B). This procedure will clear the duct in many cases. Next, a repeat cholangiogram should be performed. If the duct is clear, the cholecystectomy can then be completed in the usual fashion. If small gallstones (ie, 3 mm or less) remain in the duct but flow is demonstrated into the duodenum, observation and expectant management should be considered. A majority of small stones will pass spontaneously into the duodenum.7,8

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Figure 5 For common bile duct stones that are too large to be cleared by simple flushing, many surgeons are successful in removing these stones with a Fogarty balloon catheter. A 4-Fr Fogarty is inserted with graspers transcystically into the common bile duct past the stones. The balloon is then inflated, and the catheter is slowly withdrawn from the cystic duct with the graspers. In many cases, the Fogarty will carry the stones out of the cystic duct and into the abdomen. Following a repeat cholangiogram, the gallbladder can be removed and any free stones can be retrieved later with the gallbladder.9 Alternatively, a stone retrieval basket may be inserted through the cholangiogram catheter into the common bile duct. The basket is then opened under fluoroscopic guidance past the stone. The basket is then slowly withdrawn and closed. When the basket is unable to fully close and the stone is captured, the entire assembly is withdrawn from the cystic duct and the stone is removed into the abdomen.

Laparoscopic common bile duct exploration

Laparoscopic Transcystic Choledochoscopy Laparoscopic choledochoscopy and stone removal has been shown to be effective for the removal of bile duct stones in the majority of cases.10 A laparoscopic choledochoscope or ureteroscope with a 1.2-mm working chan-

29 nel allows the removal of stones under direct vision. Before undertaking laparoscopic common bile duct exploration, the appropriate equipment must be gathered. Table 1 shows the equipment that is needed in addition to the standard laparoscopic cholecystectomy tray. Disposable equipment is available from several manufacturers as kits and/or individual parts.

Table 1 Additional Laparoscopic Equipment Needed Flexible choledochoscope or ureteroscope with 1.2-mm working channel Laparoscopic padded graspers for manipulation of choledochoscope Second camera and light source for choledochoscope or ureteroscope Second video monitor or picture within a picture switch Pressurized saline connection for working port of choledochoscope 5-French cholangiogram or ureteral catheter 0.035-inch flexible-tipped hydrophilic guide wire 5-French angioplasty catheter with 8-mm balloon or urethral dilators 12-French abdominal wall introducer sheath Wire retrieval baskets

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Figure 6 Dilation of the cystic duct with an angioplasty balloon catheter.

Laparoscopic common bile duct exploration

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Figure 7 The catheter is then removed, in a Seldinger fashion, leaving the guide wire in place. With the guide wire in place, a plastic sheath approximately 12 Fr in diameter is placed over the wire through the abdominal wall. This allows safe passage of the choledochoscope and other equipment into the abdomen without injuring the scope’s optic fibers. Alternatively, a 3-mm inner cannula, of the type commonly used to pass an endoscopic ligation loop, can be used through a standard laparoscopic port to pass the choledochoscope. The cannula will prevent injury of the scope by the port’s valve and may be less expensive than other sheaths.

Dilating the cystic duct with an angioplasty balloon can facilitate retrieval of stones and passage of the choledochoscope through the cystic duct (Fig. 6). An 8-mm angioplasty balloon catheter is placed over the guide wire

into the cystic duct. The balloon is then inflated to 6 atm of pressure for 5 minutes. The balloon is then deflated and the catheter is removed, again leaving the wire in place. As an alternative to angioplasty balloons, which can be costly,

32 progressive urethral dilators may also be used for this purpose. A 3-mm choledochoscope or ureteroscope can then be introduced over the guide wire through the protective sheath into the abdomen. Once visualized in the abdomen, the scope can be advanced into the cystic duct with graspers, which are padded to protect the flexible scope. A separate camera, light source, and monitor are then used to observe the interior of the ducts. Alternatively, a video mixer may be used to display both the choledochoscope and laparoscope pictures on the same monitor screen. This can reduce the amount of equipment in the operating room at one time.8 Adequate visualization of the duct interior requires that pressurized saline is connected to a working side port of the choledochoscope. A water-tight valve is needed on the end of the working port to prevent the spray of saline while guide wires and baskets are used in the scope. Once a stone is encountered, the guide wire is removed and a wire retrieval basket is inserted through the working port. Under direct vision, the stone is grasped within the basket and the stone is pulled back against the end of the scope. The retrieval basket, scope, and stone are removed from the common bile duct and then the cystic duct as one unit. The stone is then released in the abdomen in a convenient location where it can be found later for removal with the gallbladder. When multiple stones are present, this process is repeated until the ducts are cleared. There are times when the scope can be advance directly into the cystic duct as the initial step. Frequently, it is easier and less frustrating to simply begin again with placement of the 5-Fr catheter, followed by the guide wire and then the choledochoscope. Although this entails more steps and movements, it can be much more reliable and less time consuming than inserting the scope directly into the cystic duct.

Troubleshooting Transcystic Common Bile Duct Exploration A frequently encountered problem with the transcystic approach is the inability to advance the scope through the cystic duct. The cystic duct can be tortuous and long, and it may contain multiple valves. The first option is to pass the angioplasty balloon or urethral dilators and dilate the duct. The duct can be very elastic and return to its initial diameter and shape if the angioplasty balloon is not given sufficient time to dilate. Another very effective option is to examine the original cholangiogram and dissect the cystic duct toward the com-

M.J. Watson, E.C. Hamilton, and D.B. Jones mon bile duct junction. There will typically be a section of cystic duct near the common duct, which is straighter and more direct. A second ductotomy can then be created in the cystic duct more distally, taking care to leave enough cystic duct to safely ligate the duct at the completion of the procedure. Another commonly seen problem is a stone that is impacted in the ampulla and cannot be removed with the basket. These stones can frequently be advanced through the ampulla into the duodenum. This can be accomplished by gentle pressure on the stone with the tip of the scope until the duodenum is visualized. Care must be taken to avoid excessive pressure on the ampulla, which might increase the risk of postoperative stricture and pancreatitis. Stones found in the hepatic ducts, proximal to the cystic duct, can present yet another challenge. Given that biliary anatomy is tremendously variable, there are situations when stones in the proximal hepatic ducts can be accessed with a transcystic approach. If the anatomy permits, dissection of the cystic duct can be performed safely to the level of the common bile duct, allowing a near 90° angle between these ducts. The head of the choledochoscope should be angled proximally once in the common bile duct, and the scope should be directed toward the hepatic ducts. This can enable passage of the choledochoscope into the proximal system and removal of stones in the manner outlined above. Most commonly, however, access to the proximal biliary tree will require a choledochotomy.

Direct Laparoscopic Choledochotomy For anatomic variations such as a very distal insertion of the cystic duct into the common bile duct or a very small cystic duct, transcystic stone removal may be precluded. In cases where there are numerous stones (greater than five or more), stones that are too large to be brought out through the cystic duct, or stones located in the proximal hepatic ducts, direct laparoscopic choledochotomy may be indicated. It is important to consider the diameter and condition of the common bile duct. For ducts less than 8 mm in diameter or those with significant overlying inflammation, the patient might be better served by endoscopic stone removal. For patients with large common bile ducts that are easily visualized, laparoscopic choledochotomy and stone extraction are good alternatives to endoscopic treatment. This is especially true when endoscopic stone removal is not practical or is impossible secondary to patient anatomy (eg, prior antrectomy).

Laparoscopic common bile duct exploration

Figure 8A Following cholangiography, the anterior common bile duct is identified near its junction with the cystic duct. The cystic duct is ligated.

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Figure 8B An endoscopic ligating loop should be used for large cystic ducts. The tissue overlying the common bile duct is cleared bluntly or with assistance of ultrasonic dissection. Electrocautery is to be avoided to prevent injury to the common bile duct. The initial ductotomy is made with small, sharp scissors. The incision is extended just far enough to allow removal of the stones and T-tube insertion.

Laparoscopic common bile duct exploration

Figure 8C Once the choledochotomy is created, the stones are removed with graspers or a Fogarty balloon as described earlier.

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Figure 9 The choledochoscope can then be inserted to inspect the proximal and distal ducts directly in order to confirm clearance of the duct system. Any additional calculi that are identified can be removed with retrieval baskets.

Laparoscopic common bile duct exploration

Figure 10 Once the duct is visually clear, a 10- to 14-Fr T-tube is cut to shape as in an open exploration. The T-tube is inserted into the ductotomy with graspers. The ductotomy is then closed around the T-tube with 4-0 absorbable sutures. Intracorporeal suturing and knot tying will reduce trauma to the edges of the choledochotomy. The end of the T-tube is pulled through a lateral port site, and a completion cholangiogram is taken.

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38 Several authors have described improved outcomes following primary closure of the common bile duct without a T-tube.11-13 Following closure of the common bile duct, the gallbladder is dissected from the hepatic bed. The gallbladder and all previously extracted gallstones are placed in a laparoscopic retrieval sac and removed from the abdomen. A closed suction drain is placed in the hepatic bed and the laparoscopic ports are removed.

Postoperative Care If a T-tube was placed, adequate time is allowed for tract formation to occur about the T-tube. Generally, 10 to 14 days is sufficient. A T-tube cholangiogram is taken before removal of the tube. Any retained stones may be removed via the T-tube sinus tract via the flexible choledochoscope (Burhenne technique).14 For transcystic exploration with secure duct ligation and a normal postoperative cholangiogram, no supplementary care is required. If the sphincter of Oddi was assessed and transgressed by the choledochoscope, a postoperative serum amylase is reasonable given the small but definable incidence of pancreatitis.

Results Randomized trials of laparoscopic versus endoscopic management of choledocholithiasis demonstrate similar rates of duct clearance.15-18 There is a slightly higher morbidity and mortality rate with endoscopic sphincterotomy than with laparoscopic exploration.19 In large reported series, transcystic common bile duct clearance alone has been found to be effective in 65% to 80% of cases.20 The overall complication rate of transcystic exploration is reported as 5% to 10%, with a mortality rate of ⬍1%. The most common biliary complications include avulsion or perforation of the cystic duct, which are usually detected intraoperatively with a completion cholangiogram. Other complications such as persistent cholangitis, pancreatitis, and retained stones often can be avoided with proper patient selection and technique.21 Most mortality is secondary to comorbid cardiac and pulmonary disease. Laparoscopic choledochotomy is highly effective at stone clearance. Most series report greater than a 90% clearance rate. The complication rate is higher than transcystic exploration. A morbidity range of 5% to 18% is reported, with a similar mortality rate to that of transcystic exploration.20

Conclusions Laparoscopic common bile duct exploration has been demonstrated to be a safe and effective alternative to endoscopic therapy. Transcystic duct exploration uses skills that are required for central venous catheter placement and flexible endoscopy. Surgeons who perform laparoscopic cholecystectomy perform these procedures as well. Laparoscopic common bile duct exploration does require additional operating room time and equipment, but it should be within the grasp of most laparoscopic surgeons. Patients benefit from a surgeon’s commitment to honing these skills in several ways. These benefits include fewer invasive procedures, lower morbidity, and an intact sphincter of Oddi at the completion of therapy.

Acknowledgments The authors thank USSC, Cook, and the Southwestern Center for Minimally Invasive Surgery, University of Texas Southwestern Medical Center, Dallas, TX.

References 1. Hamilton EC, Jones DB: Common bile duct stones, in Jones DB, Wu JS, Soper NJ (eds): Laparoscopic Surgery: Principles and Procedures (2nd ed). New York, NY, Marcel Dekker, 2004, pp 197-206 2. Bergman JJG, van der Mey S, Rauws EAJ, et al: Long-term follow-up after endoscopic sphincterotomy for bile duct stones in patients younger than 60 years of age. Gastrointest Endosc 44:643-649, 1996 3. Costamagna G, Tringali A, Shak SK, et al: Long-term follow-up of patients after endoscopic sphincterotomy for choledocholithiasis, and risk factors for recurrence. Endoscopy 34:273-279, 2002 4. Flum DR, Flowers C, Veenstra DL: A cost-effectiveness analysis of intraoperative cholangiography in the prevention of bile duct injury during laparoscopic cholecystectomy. J Am Coll Surg 196:385-393, 2003 5. Ludwig K, Bernhardt J, Steffen H, et al: Contribution of intraoperative cholangiography to incidence and outcome of common bile duct injuries during laparoscopic cholecystectomy. Surg Endosc 16:1098-1104, 2002 6. Biffl WL, Moore EE, Offner PJ, et al: Routine intraoperative laparoscopic ultrasonography with selective cholangiography reduces bile duct complications during laparoscopic cholecystectomy. J Am Coll Surg 193:272-280, 2001 7. Ammori BJ, Birbas K, Davides D, et al: Routine vs “on demand” postoperative ERCP for small bile duct calculi detected at intraoperative cholangiography. Clinical evaluation and cost analysis. Surg Endosc 14:1123-1126, 2000 8. Tranter SE, Thompson MH: Spontaneous passage of bile duct stones: frequency of occurrence and relation to clinical presentation. Ann R Coll Surg Engl 85:174-177, 2003 9. Petelin JB: Laparoscopic common bile duct exploration. Surg Endosc 17:1705-1715, 2003 10. Carroll BJ, Phillips EH, Rosenthal R, et al: Update on transcystic exploration of the bile duct. Surg Laparosc Endosc 6:453-458, 1996 11. Martin IJ, Bailey IS, Rhodes M, et al: Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures. Ann Surg 228:29-34, 1998 12. Dorman JP, Franklin ME, Glass JL: Laparoscopic common bile duct exploration by choledochotomy. Surg Endosc 12:926-928, 1998 13. Decker G, Borie F, Millat B, et al: One hundred laparoscopic choledochotomies with primary closure of the common bile duct. Surg Endosc 17:12-18, 2003 14. Burhenne HJ: Garland lecture. Percutaneous extraction of retained biliary tract stones: 661 patients. Am J Roentgenol 134:889-898, 1980 15. Cuschieri A, Groce E, Faggioni A, et al: EAES ductal stone study. Preliminary findings of multi-center prospective randomized trial comparing two-stage vs single-stage management. Surg Endosc 10:121130, 1996 16. Sees DW, Martin RR: Comparison of preoperative endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy with operative management of gallstone pancreatitis. Am J Surg 174: 719-722, 1997 17. Rhodes M, Sussman L, Cohen L, et al: Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 351: 159-161, 1998 18. Suc B, Escat J, Cherqui D, et al: Surgery vs endoscopy as primary treatment in symptomatic patients with suspected common bile duct stones: a multicenter randomized trial. French Associations for Surgical Research. Arch Surg 133:702-708, 1998 19. Tranter SE, Thompson MH: Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg 89:1495-1504, 2002 20. Moore KB, Adrales GL, Mastrangelo MJ Jr: Laparoscopic common bile duct exploration. Curr Surg 61:294-296, 2004 21. Crawford DL, Phillips EH: Laparoscopic common bile duct exploration. World J Surg 23:343-349, 1999