1. Management of CBD stone during laparoscopic cholecystectomy
Dr Wong Tak Man Mandy
Kwong Wah Hospital

2. The incidence of choledocholithiasis in patients undergoing cholecystectomy varies with age, ranging from 6% in patients less than 80 years old to 33% in patients more than 80 years old.
Johnson AG, Hosking SW. Appraisal of the management of bile duct stones. Br J Surg 1987;74:555–560.
Approximately 10% of patients who undergo laparoscopic cholecystectomy harbor common bile duct stones
Way LW, Admirand WJ, Dunphy JE (1972) Management of choledocholithiasis. Ann Surg 176: 347–359

3. It is estimated that 5% to 12% of patients with choledocholithiasis may be completely asymptomatic and have normal liver function tests.
Acosta MJ. The usefulness of stool screening for diagnosing cholelithiasis in acute pancreatitis. A description of the technique. Am J Dig Dis 1977;22:168–172.

4. 2-step approach: 1-step approach:
Lap cholecystectomy, then post-cholecystectomy ERCP
1-step approach:
Lap cholecystectomy and lap CBD exploration
Lap cholecystectomy and intra-operative ERCP
Open cholecystectomy and CBD exploration

5. 2-step approach: 1-step approach:
Lap cholecystectomy, then post-cholecystectomy ERCP
1-step approach:
Lap cholecystectomy and lap CBD exploration
Lap cholecystectomy and intra-operative ERCP
Open cholecystectomy and CBD exploration

6. Post-cholecystectomy ERCP (2-stage approach)
Failure rate: 2-4%
Need further endoscopic procedure or re- operation
Huntington TR. Laparoscopic biliary guide wire: a simplified approach to choledocholithiasis. Gastrointest Endosc 1997;45:295-7.

7. Transcystic biliary stenting
Insert a biliary stent through the cystic duct into the CBD and through the sphincter of Oddi.
Ensures access to the bile duct for postoperative endoscopic sphincterotomy.
Increase the success rate of post-operative ERCP

8. 2-step approach: 1-step approach:
Lap cholecystectomy, then post-cholecystectomy ERCP
1-step approach:
Lap cholecystectomy and lap CBD exploration
Transcystic approach
Transcholedocal approach
Lap cholecystectomy and intra-operative ERCP
Open cholecystectomy and CBD exploration

9. Lap CBD Exploration

10. Methods for stone retrieval:
Irrigation
Balloon manipulation (Fogarty catheter)
Basket maneuver
Choledochoscopy
Electrohydraulic lithotripsy
Completion cholangiogram to confirm ductal clearance, or to decide for open conversion in case of retained stones

11. LCBDE (transcystic approach)
Gallbladder is retracted toward right hemidiaphragm with forceps inserted through the most lateral port.
Cystic duct is dilated, if necessary, either with over-the-wire mechanical dilator or over-the-wire pneumatic dilator.
Choledochoscope is inserted through midclavicular port into cystic duct and guided into CBD with atraumatic forceps inserted through medial epigastric port.

12. Advantage: Disadvantage: Less invasive
Minimal morbidity, no T-tube, no drain, and a rapid return to normal activity in most cases
Disadvantage:
Limited by cystic duct diameter
Depends on the stone that need to be removed

13. Indications: Contraindications: filling defects at cholangiography
Stones smaller than 10mm
fewer than 9 stones
Contraindications:
stones larger than 1 cm
stones proximal to the cystic duct entrance into the CBD
small friable cystic duct, <3mm in diameter
tortuous cystic duct
10 or more stones

14. Applicable in more than 85% of cases Success rate of 85% to 95%
More cost effective than postoperative endoscopic retrograde cholangiopancreatography (ERCP)
S. Lyass. Laparoscopic transcystic duct common bile duct exploration. Surg Endosc (2006) 20: S441–S445

15. LCBDE (transcholedocal approach)
Longitudinal incision at supraduodenal CBD
Limited to 1 cm or diameter of the largest stone
Choledochoscope is inserted through mid- clavicular port and guided into CBD with atraumatic forceps inserted through medial epigastric port
No stay suture is required

16. Advantage: Disadvantage:
Useful in cases when transcystic method is not feasible, such as large stones, intrahepatic stones, or a miniscule or tortuous cystic duct
Disadvantage:
Technically demanding
Require suturing and knot-tying skills not necessary in the transcystic method
Limited by CBD diameter
Increased risk of post-operative bile leakage and late stenosis

17. Choledochotomy approach
Transcystic approach
N=218
Choledochotomy approach
N=44
Operating time
93.2
144.6
Hospital stay (hours)
39.2
69.8
Conversion rate (%)
0.9
Complication (%)
8.3
11.4
J. B. Petelin. Laparoscopic common bile duct exploration. Lessons learned from >12 years’ experience. Surg Endosc (2003) 17: 1705–1715

18. Transcystic or transcholedochal? Which method should we choose?

19. Transcholedochal approach
Factors influencing duct exploration approach:
Factor
Transcystic approach
Transcholedochal approach
Single stone
Multiple stone +
Stones <6mm diameter
Stones >6mm diameter -
Intrahepatic stones
Cystic duct < 4mm diameter
Cystic duct > 4mm diameter
CBD < 6mm diameter
CBD > 6mm diameter
Cystic duct entrance – lateral
Cystic duct entrance – posterior
Cystic duct entrance – distal
Inflammation – mild
Inflammation – marked
Suturing ability – poor
Suturing ability – good
+, positive or neutral effect. -, negative effect

20. 2-step approach: 1-step approach:
Lap cholecystectomy, then post-cholecystectomy ERCP
1-step approach:
Lap cholecystectomy and lap CBD exploration
Lap cholecystectomy and intra-operative ERCP
Rendezvous technique (transcystic guide wire)
Open cholecystectomy and CBD exploration

21. Intra-operative ERCP
Endoscopic sphincterotomy

22. Advantage: Disadvantage:
Allows immediate conversion under the same anaesthesia to open surgery if ERCP fails.
Disadvantage:
Difficult due to supine position
Difficult cannulation
Injection of contrast into pancreatic duct
Post-ERCP pancreatitis
Require collaboration of 2 teams – surgeon, endoscopist +/- radiologist.

23. Rendezvous technique:
After intra-operative cholangiogram, a transcystic guide wire in inserted through a small incision at cystic duct, advanced into duodenum through papilla
The tip of the guide wire is viewed using endoscope, and pulled out of patient’s mouth by a polypectomy snare
A traditional sphincterotome is introduced along the guide wire that allow direct cannulation of papilla and sphincterotomy
Stone extraction can also be performed using the guidance of the wire

24. Saccomani G. Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis. Surg Endosc. 2005;19 (7):

25. Advantage: Easy cannulation of CBD
Avoid contrast injection into pancreatic duct

26. Rendezvous technique (case series): Success rate: 95%
Failure due to difficulty in passing guide wire through the papilla
CBD stone clearance can still be achieved with traditional sphincterotomy
Complication rate: 3.7%
post-sphincterotomy bleeding (2)
post-sphincterotomy perforation (2)
death due to post-ERCP pancreatitis (1)
Giuseppe Borzellino. Treatment for Retrieved Common Bile Duct Stones During Laparoscopic Cholecystectomy. The Rendezvous Technique. ARCH SURG/VOL 145 (NO. 12), DEC 2010

27. Comparing different approach

28. Lap CBDE vs post-op ERCP

29. Nathanson 2005 , randomized trial
Post-op ERCP
(n=45)
LCBDE (choledochotomy) (n=41)
Bile leak 6
Pancreatitis
Biochemical 4 3
Clinical (Glascow score)
1 (2)
1 (4)
Severe sepsis 1
Retained stone 2
GI bleed
Open conversion
Re-operation
3 (6.6%)
3 (7.3%)
Significant morbidity
6 (13%)
7 (17%)
Hospital stay (days)
7.7
6.4
Nathanson LK. Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial. Ann Surg. 2005;242(2):

30. LCBDE (choledochotomy)
Nathanson (n=86)
Rhodes (n=80)
LCBDE (choledochotomy)
n=43
Post-op ERCP
LCBDE (transcystic)
n= 40
n=40
Primary ductal clearance (%)
100 74 75
Final ductal clearance (%) 93
Morbidity (%) 17 13
Mortality (%)
Hospital stay (days)
6.4
7.7 1
3.5
Edward H. Phillips. Treatment of Common Bile Duct Stones Discovered during Cholecystectomy. J Gastrointest Surg (2008) 12:624–628

31. The re-operation rate for LCBDE is comparable to post-op ERCP
Nathanson 2005
Berci 1994
Re-operation after Lap CBDE
7.3% 5%
Re-operation after failed post-op ERCP
6.6%
4-8%
The re-operation rate for LCBDE is comparable to post-op ERCP
Berci G, Morgenstern L. Laparoscopic management of common bile duct stones: a multi-institutional SAGES study. Society of American Gastrointestinal Endoscopic Surgeons. Surg Endosc. 1994;8:1168–1174.

32. Severely inflammed friable tissue  for post-op ERCP
CBD less than 7 mm
Severely inflammed friable tissue
 for post-op ERCP
Patient with Billroth II gastrectomy
Failed ERCP access
Long delay to transfer patient to other locations for ERCP
 for LCBDE
Nathanson LK. Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial. Ann Surg. 2005;242(2):

33. Intra-op ERCP vs post-op ERCP

34. Rendezvous technique:
High success rate in clearing ductal stones (94%)
Less complications (especially pancreatitis)
Mean hospital stay is similar to simple lap cholecystecyomy
Although operating room time of combined method is longer than simple lap cholecystectomy
Iodice G. Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique. Gastrointest Endosc. 2001;53(3):

35. Success rate of CBD clearance 90.2% 96.6% 95.6% 80% (p=.06)
Rabago 2006
Morino 2006
Rendezvous (n=59)
2-stage
(n=64)
Rendezvous
(n=46)
(n=45)
Success rate of CBD clearance
90.2%
96.6%
95.6%
80%
(p=.06)
Post-ERCP pancreatitis
1.7%
12.7%
(p=.03)
2.2% 0%
Mean hospital stay
4.3 days
8 days
Mean hospital cost
2829€
3834€
Rabago LR. Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis. Endoscopy. 2006;38(8):
Morino M. Preoperative endoscopic sphincterotomy versus laparoendoscopic rendezvous in patients with gallbladder and bile duct stones. Ann Surg. 2006;244(6):

36. Intra-operative ERCP (Rendezvous technique) has high success rate of CBD clearance, and less post-ERCP pancreatitis when compared to the 2-stage method.

37. LCBDE vs intra-op ERCP

38. Prospective study
LCBDE (n=141)
LC + IO ERCP (93)
Surgical time (min) / /
Stones (n)
2.52 +/- 1.62
2.26 +/- 1.55
Surgical success rate (%)
89.36
91.4
Stone size (mm)
4-40
5-15
Retained stones (%)
2.38
1.17
Complications (%)
5.55
9.42
Hospital charge (RMB) / /
Post-op hospital stay (day)
4.66 +/- 3.07
4.25 +/- 3.46
No difference in terms of surgical time, number of extracted stones, retained CBD stones, hospital charges and post-operative hospital stay.
Hong DF. Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis. Surg Endosc. 2006;20(3):

39. Systemic review
LCBDE
LC + intra-op ERCP
Surgical success rate (%)
80-99 (96)
79-98 (92)
Stone clearance (%)
(95)
75-96 (91)
Mortality (%)
0-5 (1)
0-6 (1)
Complications (%)
2-17 (8)
3-16 (13)
Tranter SE, Thompson MH (2002) Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg 89: 1495–1504

40. Both LCBDE and LC + intra-op ERCP are safe and effective
Stones larger than 20 mm are not suitable for stone removal by endoscopic sphincterotomy
Excessive cutting of sphincter may increase complications
Hong DF. Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis. Surg Endosc. 2006;20(3):

41. 2-step approach: 1-step approach:
Lap cholecystectomy, then post-cholecystectomy ERCP
1-step approach:
Lap cholecystectomy and lap CBD exploration
Lap cholecystectomy and intra-operative ERCP
Open cholecystectomy and CBD exploration

42. Open CBD exploration
Open CBDE remains the “gold standard” for selected, rare patients such as those with Mirizzi syndrome, Billroth II anatomy, and those requiring a drainage procedure.
Morbidity from 11% to 14%
Mortality from 0.6% to 1%.
Morgenstern L, Wong L, Berci G. Twelve hundred open cholecystectomies before the laparoscopic era. A standard for comparison. Arch Surg 1992;127:400–403.

43. 2-step approach: 1-step approach:
Lap cholecystectomy, then post-cholecystectomy ERCP
Transcystic biliary stenting
1-step approach:
Lap cholecystectomy and lap CBD exploration
Transcystic approach
Transcholedocal approach
Lap cholecystectomy and intra-operative ERCP
Rendezvous technique
Open cholecystectomy and CBD exploration

44. Edward H. Phillips. Treatment of Common Bile Duct Stones Discovered during Cholecystectomy. J Gastrointest Surg (2008) 12:624–628

45. However, it is unrealistic to extrapolate standards of care based on the available RCTs given the wide variation in skills and resources available in different communities.
Individual surgeons must recognize their own limitations and the limitations of available endoscopists and perform the safest approach.

46. Conclusion
Lap CBD exploration is comparable to post- op ERCP in terms of ductal clearance, morbidity and re-operation rate.
Lap CBD exploration is comparable to intra- operative ERCP in terms of success rate, stone clearance and complications.
Intra-operative ERCP has higher success rate and less complications (esp. pancreatitis) when compared to post-op ERCP

47. Decision depends on: Stone number and size
Cystic duct size and anatomy
CBD size
Severity of tissue inflammation
Past surgical history
Surgeon’s experience

48. THANK YOU!

51. What are the methods for closing choledochotomy?

52. Choledochotomy can be closed by either primary closure or insertion of T-tube
Choledochotomy is closed with 40 or 50 vicryl, either interrupted or continuous suture.
T-tube:
The entire 14-French T-tube is placed into abdomen
Then the “T” is inserted into the CBD

53. Use of T-tube is based on for three primary factors:
decompression of the duct, in the case of residual distal obstruction;
ductal imaging in the postoperative period
provision of an access route for removal of residual CBD stones, should they be left after CBD exploration
Williams JAR. (1994) Primary duct closure versus T-tube drainage following exploration of the common bile duct. Aust N Z J Surg 64: 823–826

54. Drawbacks of T-tubes during postoperative period:
Bacteremia
Dislodgment of the tube
Obstruction by the tube
Fracture of the tube
Removal of T-tubes has been associated with bile leaks, peritonitis, and reoperation

55. T-tube cholangiography should be performed before removal of the tube
Removal of T-tubes has been suggested as early as 4 days postoperatively and as late as 6 weeks after surgery
Norrby S (1988) Duration of T-tube drainage after exploration of the common bile duct. Acta Chir Scand 154: 113–115

56. With T-tube
Primary closure
No. of cases 33 12
Operating time
155.3
115.4
Hospital stay (hours)
80.9
39.4
Conversion rate (%)
Complication (%)
15.2
8.3
Selective laparoscopic placement of T-tubes in patients requiring choledochotomy is a safe and effective alternative to routine T-tube drainage of the ductal system
J. B. Petelin. Laparoscopic common bile duct exploration. Lessons learned from >12 years’ experience. Surg Endosc (2003) 17: 1705– 1715

57. Emergency situation? Emergency LCBDE N=48 Elective LCBDE N=33
Bile leak
2 (4%)
1 (3%)
Supraventricular tachycardia
1 (2%)
Hyperkalaemia
Incisional hernia
Jaundice and ERCP
Impacted dormia basket
Urinary retention
Paralytic ileus
Sepsis
Death
Ali Alhamdani. Primary closure of choledochotomy after emergency laparoscopic common bile duct exploration. Surg Endosc (2008) 22:2190–2195

58. Safe for primary closure in emergency setting by comparing it to the elective setting.
Moreover, no difference was shown in operative time or the hospital stay between the two groups