Chapter 6: Treatment - Open Surgery

       The last 30 years have seen major developments in the management of gallstone-related disease. ERCP has become a widely available and routine procedure, whilst open cholecystectomy has largely been replaced by a laparoscopic approach, which may or may not include laparoscopic exploration of the common bile duct (LCBDE). As a consequence clinicians are now faced with a number of potentially valid options for managing patients with suspected CBDS. These options can be divided into three main approaches: open surgical maneuvers, endoscopic maneuvers and laparoscopic maneuvers (Williams et al., 2008).

                In general, open common duct exploration is indicated when stones are palpable or discovered by cholangiography during open cholecystectomy. It may be indicated when stones are discovered during laparoscopic cholecystectomy and the surgeon is not familiar with the technique of laparoscopic duct exploration (Prystowsky 2005).

The following are the princible indications of open CBD exploration.

1.     After conversion of laparoscopic to open cholecystectomy.

2.     When laparoscopic and endoscopic expertise is not available.

3.     Patient informed choice.

4.     Relative contraindications of laparoscopic maneuvers (Gigot 2007).

               Conversion from laparoscopic to open cholecystectomy should not be considered a complication, but is rather a wise decision as an attempt to avoid complications and ensure patient safety. Factors which are associated with conversion to open cholecystectomy include: acute cholecystitis with a thickened gallbladder wall, previous upper abdominal surgery, male gender, advanced age, obesity, bleeding, bile duct injury. Overall conversion rates have been reported to be between 2-15%. Ultimately, individual surgeons must base the decision to convert to an open procedure on their own intraoperative assessment, weighing the severity of inflammatory changes, clarity of the anatomy, and their skill/comfort in proceeding (Overby et al., 2010).

         The following table summerize the cuases of conversion to open surgery that were illustrated by 8 recent studies.

       Genc et al. defined possible risk factors that may correlate with conversion to open surgery in a large series of 5164 attempted laparoscopic cholecystectomy. Male gender was found to be the only significant cause of conversion among the possible causes investigated in this study (Genc et al., 2011).

Relative contraindications for laparoscopic biliary tract surgery include many of the usual contra-indications for laparoscopic surgery in general. These include, but are not limited to, generalized peritonitis, septic shock from cholangitis, severe acute pancreatitis, untreated coagulopathy, lack of equipment, lack of surgeon expertise, previous abdominal operations which prevent safe abdominal access or progression of the procedure, advanced cirrhosis with failure of hepatic function, and suspected gallbladder cancer. Indications for planned open procedures include a patient’s informed request for an open procedure, known dense adhesions in the upper abdomen, known gallbladder cancer, and surgeon preference (Overby et al., 2010).

In a recent Egyptian prospective study comparing laparoscopic versus open cholecystectomy in cirrhotic population, the rate of conversion to open cholecystectomy (7.33%) was similar to published data for laparoscopic cholecystectomy in non cirrhotic patients’ population. These results favor the exclusion of cirrhotic liver from being a relative contraindication of laparoscopic biliary surgery (El-awadi et al., 2007).

Common Bile Duct Exploration can be performed either via Supraduodenal choledochotomy or Transduodenal Sphincteroplasty.

Supraduodenal choledochotomy  is performed through right subcostal or upper middle-line incision. The hepatoduodenal ligament is easily stretched  by pulling up the quadrate lobe using a retractor and pulling down the pancreatic head by using the assisting surgeon’s hand (Gigot 2007).

Step 1. Once the common duct has been identified, its anterior wall should be exposed for about 2.5-3 cm; care should be taken to avoid dissection along its lateral walls since that is where its blood supply exists.

Step 2. A blade is used to create a small rent in the anterior wall of the duct between 2 stay sutures, and Potts scissors are used to enlarge the rent in a longitudinal fashion for about 2 cm.

Step 3. Randall stone forceps are passed distally and then proximally to clear the duct of stones by directly grasping them.

Step 4. A choledochoscope is useful to identify residual stones and assist in their extraction.

Step 5. An appropriately sized T-tube is placed into the common duct, and the common duct closed over the tube with a series of interrupted 4-0 absorbable sutures.

Step 6. A cholangiogram is performed to ascertain that the duct is clear of stones.

Step 7. A drain is placed near the CBD opening and brought out through a separate stab incision. The remainder of the case proceeds as for open cholecystectomy (Prystowsky 2005) .

          The CBD was traditionally closed over a T-tube. A relatively fine T-tube (10 or 12 Fr) should be used. The short limbs of the T-tube are inserted into the CBD via the choledochotomy incision (Fig. 12), which is closed using interrupted 4/0 PDS sutures. The long limb of the T-tube is brought out to the surface through a stab incision, taking the most direct route. A T-tube cholangiogram is then taken on the 7th to 14th postoperative day to ensure there are no retained stones. If the cholangiogram is normal, the T-tube is clamped. Removal of the T-tube will depend on the material from which it is made, as this will determine the length of time for a track to form. If it is latex rubber, the T-tube can be removed at 10–14 days, but if it is silastic it should be left for 3–4 weeks before removal. Following removal of the T-tube, there may be a little bile leak that persists for 1–2 days  (Parks et al., 2005).

       A good alternative to CBD decompression other than T-tube is the use of internal biliary stents, widely used in endoscopic procedures and recently also as an alternative to the T-tube during laparoscopic choledochotomy. Several studies have demonstrated the usefulness of these stents and their advantages with respect to the T-tube, as they are associated with fewer complications and avoid the discomfort of the T-tube. Biliary stents are removed 3 weeks later using upper GIT endoscpoe (Escalona et al., 2005).

                 If a stone remains impacted at the lower end of the CBD, despite routine measures to remove it, the surgeon has a numbers of approaches, depending on the fitness of the patient or availability of endoscopic skills:

·        To leave the stone in situ, drain the CBD by T-tube for 2–3 weeks to allow inflammation to settle,and then to perform an ERCP, sphincterotomy and endoscopic stone removal. For the very sick patient, this may be appropriate, but truly impacted stones can bevery difficult to remove at ERCP, and certainly stones over 15 mm are not suitable for this technique.

·        To leave the stone in situ and perform a choledochojejunostomy

·        To remove the stone via a transduodenal sphincteroplasty (Parks et al., 2005).

                Transduodenal sphincterotomy is useful in the management of choledocholithiasis when there is stone impacted in the ampulla of Vater that is not removable by any other means, papillary stenosis, and multiple stones, particularly in the presence of a mildly dilated CBD. It is also indicated for the treatment of sphincter stenosis or dysfunction in selected cases (Denham 2005).

              An oblique anterolateral incision is made in the second part of the duodenum. Stay sutures are then inserted in the medial wall of the duodenum on either side of the ampulla. Using a blade, an incision is made directly over the stone, which is then extracted. The incision in the wall of the duodenum and lower end of the CBD is then enlarged using Pott’s scissors, to a minimum length of 15 mm and converted to a formal sphincteroplasty by approximating duodenal and CBD mucosa using interrupted 4/0 PDS sutures. Care must be taken to ensure apposition of mucosa at the apex of the incision. The duodenum is closed transversely in two layers to prevent narrowing. Supraduodenal T-tube drainage is not normally necessary following this procedure (Parks et al., 2005)

          Regarding the complications that may occur, wound infection is a risk in the face of infected bile. Bleeding from the sphincteroplasty may occur. If the sphincteroplasty is carried too deep, the duodenal wall may be perforated and retroperitoneal leakage occurs. The duodenal closure can leak. Also acute pancreatitis may occur (Denham 2005).

                 A choledochoduodonstomy was often preferred method of surgical bypass in benign diseases. The supraduodenal CBD is anastomosed to the duodenum, as illustrated in (Fig. 15) (Parks et al., 2005).

 

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