While laparoscopic cholecystectomy is considered the treatment of choice for symptomatic cholecystolithiasis, the management of common bile duct stones (CBDS) is still controversial. There is no consensus about CBDS treatment except for residual stones, complicated CBDS (suppurative cholangitis, severe pancreatitis), and high-risk patients, which are indications for endoscopic sphincterotomy (ES). The treatment of choledocholithiasis since the development of laparoscopic cholecystectomy has often been ES combined with laparoscopic cholecystectomy in a two-stage procedure that adds the complications of both procedures. Therefore, it seemed logical to develop a mini-invasive one-stage procedure using the laparoscopic approach. This study evaluates our results of laparoscopic common bile duct stones extraction in a series of 504 patients.

Materials and methods

From October 1990 to September 2006 all patients who underwent a laparoscopic common bile duct stones extraction were included in a prospective study. They were managed in two hospitals. This series of 505 patients included 354 women and 151 men. The mean age was 63 years (range = 19–93). Four hundred fifteen patients were classified ASA I and ASA II and 90 were ASA III and ASA IV. One hundred twenty-five patients (25%) had previous abdominal surgery. Preoperative evaluation was done through medical history, biochemical tests, and ultrasonography. No other preoperative exploration was performed because all patients undergoing cholecystectomy had routine intraoperative cholangiography (IOC). Common bile duct stones were diagnosed or suspected preoperatively in 373 patients (73.8%) or identified at IOC in 132 patients (26.2%).

Technique

The surgical technique described in detail previously [1] is outlined briefly. The first step of the procedure is IOC which confirms or diagnoses CBDS and provides information about the number, size, and location of the stones and the anatomy of cystic and common bile ducts. The choice between transcystic duct extraction (TCDE) and choledochotomy depends on this information.

TCDE

The TCDE was used for small stones (<7 mm) located below the cystic duct implantation on the common bile duct (CBD). In the majority of TCDE the cystic duct needs to be dilated. Dilation is performed with blunt, flexible dilators introduced by a 5-mm trocar inserted upright to the cystic duct opening. After dilation a 3-mm flexible choledochoscope is introduced into the cystic duct. Small stones can be flushed or pushed through the papilla, but in the majority of cases the stones are extracted with a Dormia basket under choledochoscopic control. After extraction a completion cholangiography has to be performed because upper bile ducts are accessible to choledochoscopy in only 10%–15% of cases. Then the cystic duct is usually closed with an absorbable suture. A transcystic biliary drainage is used only in case of cholangitis .

Choledochotomy

A choledochotomy is indicated for large stones (>7 mm), numerous stones (>5), or when the stones are located above the cystic duct implantation into the CBD and after failure of TCDE. The first step is to achieve good exposure of the porta hepatis. It is obtained by lifting the round ligament with a transparietal suture and by pulling the cystic duct up and laterally. The anterior aspect of common bile duct is cleared on a length of 10 to 20 mm.The choledochotomy is performed vertically on the supraduodenal part of the anterior aspect of the CBD.

The CBDS extraction is the most difficult step. All the stones visible through the choledochotomy can be extracted with atraumatic forceps. Stones located in the lower part of the CBD can be pushed through choledochotomy by pressure on the CBD wall with blunt forceps or flushed through the choledochotomy with saline irrigation. The remaining stones are extracted with a Dormia basket under choledochoscopic guidance. The most difficult cases to manage are impacted stones because often they cannot be extracted with a Dormia basket so electrohydraulic lithotripsy needs to be used. Once the stones are fragmented they are retrieved with a Dormia basket or pushed through the papilla. We have never used papilla dilation because of the risk of pancreatitis.

Once the stones extraction is over, the choledochotomy is closed with an absorbable running suture and a completion IOC is performed to check that there are no residual stones and to check the watertightness of the suture. A biliary drainage by T-tube rather than a transcystic drain is used in case of cholangitis, porta hepatis inflammation, or when the number of stones is more than 5 or 6. In all cases a subhepatic drainage is used.

In case of biliary drainage a cholangiography is performed on the third postoperative day. If there is no residual stone, the drain is closed and will be removed on an outpatient basis on the 21st postoperative day.

Results

From October 1990 to September 2006, a laparoscopic treatment of CBDS was performed in 505 patients with a success rate of 96.2%. A TCDE was attempted in 254 cases with success in 191 cases (75.2%). The main causes of failure were impacted stones and stones larger than 5 mm. The 63 failures were managed by laparoscopic choledochotomy with success in 53 patients and by ES in 10 patients, four times intraoperatively and six times postoperatively.

Stones extraction by laparoscopic choledochotomy was performed in 304 patients, by first intention in 251 patients and after failure of TCDE in 53 patients. The success rate was 97%. The causes of failure were an impacted stone in eight cases and an intrahepatic duct stone in one case. The nine failures were managed by conversion to laparotomy in six cases (2%) and by postoperative ES in three cases. The overall success rate of laparoscopic treatment of CBDS was 96.2%.

Biliary drainage after TCDE was used in 17.8% of cases and in 48.8% of cases after choledochotomy. The mean operative time was 124 min (range = 40–360). It was 96 min in TCDE and 137 min in choledochotomy. The mean postoperative hospital stay was five days after TCDE and eight days after choledochotomy.

The complication rate was 7.9%, including 3.1% of local complications and 4.8% of general complications (Table 1) and the mortality rate was 1%. The most frequent local complications were biliary: three biliomas of which one needed a percutaneous drainage, and eight bile leaks of which one was managed laparoscopically, one by ES, and six stopped spontaneously. Two cases of cholangitis occurred in patients with T-tubes and were cured with antibiotics. There were two cases of biliary peritonitis, one at the time of T-tube ablation. They were managed by laparoscopy with one death due to cardiac failure.

Table 1. Complications of laparoscopic treatment of CBDS in 504 patients
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The most frequent general complications were cardiopulmonary: nine cases with one death following myocardial infarction in an ASA III patient and one death due to respiratory failure in an ASA III patient. There were three patients with multiorgan failures. These patients had severe comorbid conditions which were failures of preoperative ES with one death in an ASA IV patient. Two cases of pancreatitis occurred, with one managed conservatively and one needed reoperation for necrosectomy. The fifth death was due to collapse of liver cirrhosis.

Table 2 presents the complications with respect to ASA stage, age, and technique of stones extraction. There were 14 residual stones (2.8%): four after TCDE early in the series and ten after choledochomy. They were managed by a 2° laparoscopy in three cases and postoperative ES in 11 cases, with four failures managed by laparotomy in one case and by laparoscopy in three cases.

Table 2. Complications related to ASA stage, age and technique of desobstruction
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The follow-up period ranged from 1 to 180 months (median = 108 months). Late complications occurred in 1.8% of patients (Table 3). There were six cases (1.2%) of recurrent lithiasis, one case of common bile duct stenosis (0.2%) due to a lost stone behind the CBD which was managed by an hepaticojejunostomy after failure of a biliary stent, and two cases of trocar site hernia.

Table 3. Late complicationsa
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Discussion

Laparoscopic cholecystectomy is considered the gold standard for the treatment of symptomatic cholecystolithiasis. Therefore, it seemed logical to extend the benefits of the laparoscopic approach to the treatment of CBDS, with the aim of having less morbidity and mortality that is associated with open surgery, to avoid specific complications and sequelae of ES [2, 3], and to treat the patient with a single-stage procedure.

The choice of the procedure (ES with subsequent LC or laparoscopic management) has to take into account several elements: the comorbidities of the patient, the complications of CBDS, a previous cholecystectomy, the skills of the surgeon and the endoscopist [4], and the early and late results of both procedures [2, 5, 6].

There is a consensus for ES in specific circumstances: suppurative cholangitis, severe pancreatitis, high-risk patients, and patients who had previous cholecystectomy [4, 7, 8]. While in the early era of LC the majority of CBDS were managed by ES [9, 10] to avoid an open procedure, the development of laparoscopic techniques of stones extraction and their results have induced one to reconsider this approach.

The systematic use of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in patients with suspicion of CBDS results in a rate of 50%–60% of negative exploration [3, 10]. ERCP can now be replaced by echoendoscopy, which is invasive and needs general anesthesia, or by resonance magnetic imaging cholangiography. On the other hand, when laparoscopic management is considered, there is no need for preoperative invasive exploration because the diagnosis of CBDS is based on routine IOC [1, 11, 12]. Because we do not perform preoperative exploration except liver function tests and ultrasonography, 26.2% of patients with CBDS in our series had stones diagnosed at IOC, confirming the fact that preoperative prediction of CBDS is poor.

No randomized study has demonstrated the superiority of the treatment of CBDS by ES. Neoptolemos et al. [7] has demonstrated that this treatment does not bring any benefit over open surgery in patients fit for surgery.

The randomized studies comparing ES combined with LC to laparoscopic management report similar success rates [13–15]. In these studies the success rate varies from 82% to 96%, the morbidity rate varies from 10% to 17%, and the mortality rate varies from 0% to 2%, with a hospital stay shorter for laparoscopy. Cuschieri et al. [14] conclude that laparoscopic treatment is preferable for ASA I and ASA II patients, while ES is indicated for high-risk patients.

Prospective studies of laparoscopic management of CBDS that included more than 200 patients [1, 12, 16–20] report success rates ranging from 88% to 97% (mean 92%), similar to ES success rates which range from 81% to 100% (mean 91%), but the clearance of CBDS after ES is obtained in 17%–35% of cases after two to five attempts [21–23], while laparoscopic treatment of CBDS is a one-stage procedure.

The morbidity rate after ES followed by LC ranges from 3% to 16% (mean 13%), while after laparoscopy it ranges from 7% to 19% (mean 8%) [24]. The mortality rate after ES + LC ranges from 0% to 6% (mean 2%) and is twice the rate after laparoscopy which is 1% (range = 0%–5%) [24]. In our series we had a success rate of 96.2%, a morbidity rate of 7.9%, and a mortality rate of 1%. The morbidity in our series was significantly higher for high-risk patients (ASA III and IV) and after choledochotomy than after TCDE, while the age has no influence on morbidity (Table 2).

The most frequent complications after laparoscopic treatment are biliary (Table 1). Several studies attribute this to the biliary drainage [16, 25–27]. Comparing the use or the absence of biliary drainage after choledochotomy, Thompson and Tranter [16] reported a complication rate of 16% following the use of the T-tube, while it was only 5% for primary closure. However, in our series, as in that of Paganini and Lezoche [11], we did not have the same results. There were 13 biliary complications after choledochotomy (4.3%): five occurred after primary closure of CBD, seven in patients with a T-tube, and one after transcystic drainage. Early in our practice we frequently used biliary drainage but now we use it selectively, e.g., in case of cholangitis or porta hepatis inflammation or when the number of stones is greater than six or seven because the risk of residual stones is increased in this case. It has been proposed that the T-tube be replaced by an antegrade stent [10] but this entails the risk of pancreatitis [28] and a second procedure is needed to remove the stent.

Acute pancreatitis, which is the most frequent and severe complication after ES (3%), is uncommon after laparoscopic management of CBDS [24]. In our series we had two cases (0.4%), one resolved spontaneously and the second needed a reoperation.

The rate of residual stones after laparoscopic treatment ranges from 2.6% to 8% (mean 5%) and is equivalent to that of open surgery [29]. However, if we consider that all stones remaining after the first attempt of stones extraction are residual stones, the rate of residual stones after ES ranges from 17% to 35% [21–23], far more frequent than for laparoscopic management. In our series we had a rate of 2.8% of residual stones. To minimize the risk of residual stones it is necessary to perform choledochoscopy and completion cholangiography after stones extraction in all patients.

Only a few publications deal with late complications of laparoscopic desobstruction of CBDS [20, 30, 31]. The rate ranges from 0% to 3.2%, while after ES it ranges from 2% to 22% [24]. The most frequent complications are recurrent stones. Tanaka et al. [32] report a continuing accrual of recurrent stones up to 25 years after ES. In a series of 331 patients who were managed laparoscopically and followed for a median of 43 months, Riciardi et al. [30] observed no biliary complications. In our series, after a median follow-up of 108 months (range = 2–180) we observed a 1.8% rate of late complications, including six cases of recurrent stones [1.2%], two cases of trocar site hernia, and one case of CBD stenosis due to a lost stone behind the CBD that was managed by a biliary stent but which failed and a hepaticojejunostomy was needed. This case demonstrates that it is very important to avoid the loss of stones in the abdominal cavity. The low rate of late complications is probably one of the most important benefits of laparoscopic management over ES; this is a particularly important factor when treating young patients.

The laparoscopic treatment of CBDS can be performed by a transcystic approach or by choledochotomy, with each technique having its own indications. The choice between these two techniques depends on information provided by IOC, i.e., the size, number, and location of the stones and the anatomy and diameter of the cystic duct and CBD.

In the literature TCDE was used in 26%–93% (mean 71%) [13, 16, 17, 19, 33] of the cases (50% in our series), with a success rate ranging from 74% to 98% [13, 16, 17, 19, 33, 34.]. In our series TCDE was performed in 50.4% of cases and successful in 75.2%. The 63 failures were managed by laparoscopic choledochotomy in 52 cases and by postoperative ES in 11cases early in the series. The majority of failures would be probably now treated by laparoscopy. The main causes of failure were impacted stones and stones whose size was greater than 5 mm. The best way to deal with impacted stones is electrohydraulic lithotripsy [1, 10, 11, 16] under choledochoscopic guidance which we did in eight patients. In our practice the transcystic approach is used for small stones (<7 mm) if the number of stones is fewer than five or six and if the stones are located below the cystic duct-CBD junction. It is also indicated in case of porta hepatis inflammation because the dissection of the CBD can be difficult.

Choledochotomy by first intention is indicated when the stones are larger than 7 mm, there are more than five or six, when the stones are located in the proximal biliary tree. The necessary conditions to perform a choledochotomy are a CBD diameter of 5 mm or more and a proficiency in laparoscopic sutures. As for TCDE, the main cause of failure is impacted stones that can be fragmented with electrohydraulic lithotripsy.

The rate of complications and the postoperative hospital stay depend on the technique of stones extraction used. Similar to the Thompson and Tranter series [16], in our series the advantages of TCDE are a significantly lower rate of morbidity and a shorter hospital stay than that after choledochotomy: 4.2% vs. 10.4% and 5 days vs. 8 days (Table 2).

Conclusion

The laparoscopic management of CBDS has the advantage over ES followed by LC because it is a one-stage procedure. However, these two techniques are not opposite but complementary, each having its own indications. The laparoscopic treatment of CBDS is particularly indicated in ASA I and ASA II patients because it is a safe procedure in terms of short-term outcome and late sequelae. Any time it is feasible, transcystic extraction is preferable to choledochotomy because of its lower rate of complications and its shorter length of hospital stay.