Laparoscopic Management of Biliary Stone Disease

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.

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 setting.

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.

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).

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.