Chapter 8: Laparoscopic maneuvers of treatment of CBD stones

            Advances in new technology and medications in medicine occur in two ways: evolutionary or revolutionary. The majority of time they are evolutionary, based on discovery and incremental innovation in the scientific community and the academic medical centers. On the other hand, the introduction of laparoscopic cholecystectomy was a revolutionary change. When first introduced, there was a rush for practicing surgeons to acquire this new technique and incorporate it into their practice. This resulted from the clear advantages that the technique provided patients in terms of reduced abdominal wall scarring, hospitalization, and time off work. It also was driven by economics of surgical practice. Early on it became readily apparent to the public through media coverage that there was a new technique for gall bladder removal (Ellison et al., 2008) .

        The logical extension of this procedure was the introduction of laparoscopic CBD exploration (LCBDE) for suspected or proved ductal stones (Memon et al., 2000).

          The most common indication for LCBDE is an abnormal IOC. Preoperative abnormalities that suggest a possible need for LCBDE are listed in Table (7).

Table (7): Preoperative abnormalities suggesting that LCBDE may be required (Petelin et al., 2004).

Clinical history	·        Jaundice, Pancreatitis
Liver function tests	·        High bilirubin ·        High Alkaline phosphatase ·        High Gamma-glutamyl transferase
Ultrasound	·        Dilated bile ducts ·        Choledocholithiasis ·        Ductal obstruction
ERCP (or, rarely, transhepatic cholangiography)	·        Choledocholithiasis

        Relative contraindications for laparoscopic biliary tract surgery include many of the usual contraindications for laparoscopic surgery in general. These include, but are not limited to, Absence of any of the indications, 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 (Overby et al., 2010).

Regarding the operating room setup and instruments, the patient is placed supine. The surgeon stands between the patient’s legs. The first assistant is on the patient’s right side while the second assistant is on the left. Two video monitor sets are required for this procedure; one for the actual laparoscopic part and the second for cholangioscopy. The laparoscopic monitor is placed left of the patient’s head, while the cholangioscopy monitor is on the right. Some reverse Trendelenburg position is required, and slight left rotation at times (Dulucq 2005).

 

 

Different approaches for laparoscopic management of CBD stone

          

       With increasing laparoscopic expertise, exploring the common bile duct either via (A) transcystic laparoscopic common bile duct exploration (TC-LCBDE), (B) common bile duct exploration via choledochotomy (Overby et al., 2010).

            There are many factors that influence the choice of the approach to LCBDE. These factors can be divided to: factors related to the stone itself; number, size, and site, factors related to the cystic duct; diameter and entrance to the CBD, factors related to the inflammation and its degree, finally factors related to the skills of the operating surgeon, particularly his suturing ability. It must be mentioned that negative factors have a more profound impact on choice of approach than positive or neutral ones. The following table summarizes these factors and their impact on the choice of the approach (Petelin 2006).

Table (8): Factors influencing the choice of the approach to LCBDE (Petelin 2006).

Factor	Transcystic	Choledochotomy
One stone	+	+
Multiple stones	+	+
Stones <6mm diameter	+	+
Stones >6mm diameter	-	+
Intrahepatic stones	-	+
Diameter of cystic duct <4mm	-	+
Diameter of cystic duct ≥4mm	+	+
Diameter of common duct <6mm	+	-
Diameter of common duct ≥6mm	+	+
Cystic duct entrance—lateral	+	+
Cystic duct entrance—posterior	-	+
Cystic duct entrance—distal	-	+
Inflammation—mild	+	+
Inflammation—marked	+	-
Suturing ability—poor	+	-
Suturing ability—good	+	+

 

(A) Transcystic laparoscopic common bile duct exploration

       

       TC-CBDE is generally attempted before laparoscopic choledochotomy because it is both possible and highly successful in the majority of cases, and because it is less invasive than laparoscopic choledochotomy. In addition, TC-CBDE does not usually require facility with laparoscopic suturing techniques. The transcystic approach is particularly useful when the cystic duct is ample in diameter and enters the CBD via a relatively straight, lateral approach (Petelin 2006). 

           Studies have shown a high success rate and low morbidity with TC-CBDE. After a cholangiogram has been obtained and correctly interpreted, small stones (<4 mm) may be flushed through the duct after the administration of intravenous glucagon to relax the sphincter of Oddi. This should be done under the guidance of fluoroscopy. If this fails to clear the duct and the stone appears small enough to pass through the cystic duct, a wire basket may be used to capture and retrieve the stone. Larger stones may be crushed prior to attempted extraction and smaller cystic ducts can be dilated prior to manipulation. The passage of a 3 mm choledochoscope into the cystic duct allows for direct visualization, capture, and retrieval of stones. Although these methods have been highly effective in the hands of trained surgeons, they are technically demanding and time consuming (Chand et al., 2006).

External biliary drainage

             When a stone is discovered at the time of laparoscopy, and the surgeon is unable to remove the stone from the CBD, a drain may be left transcystically. The tube is placed laparoscopically into the cystic duct with its tip into the CBD and the tube secured with a pre-tied ligature. The drain is then brought out through the skin, much as a T-tube would be, and left to gravity drainage. This tube allows for decompression of the biliary system and also future access of the biliary tract. A wire maybe passed through this drain into the duodenum to facilitate endoscopic therapy. Once the duct has been swept clear of stones the drain may be capped and subsequently removed after 2-3 weeks, after a secure tract has formed (Chand et al., 2006).

Transcystic biliary drains are also advocated to be inserted despite complete clearance of CBD of multiple stones due to fragmentation of stones and because of repeated manipulations, including passage of the Dormia basket through the papilla (Hanif et al., 2010).

Internal biliary drainage

            This entails the use of a small caliber biliary stent that is passed through the cystic duct into the duodenum. Once a cholangiogram demonstrates a filling defect in the common bile duct, a guide wire is passed transcystically into the duodenum with the use of fluoroscopy. A 7Fr, 5-cm long biliary stent is then passed over the wire and “pushed” into the duodenum with a pusher tube of similar size. The stent is fluoroscopically guided through the cystic duct, CBD, and partially into the duodenum. The pusher tube and guide wire are then removed. The cystic duct is then clipped and the cholecystectomy completed. The patient can then be discharged the same day and returns for further endoscopic therapy. The stent has the advantage of allowing for continued internal drainage of the biliary system and therefore preventing potential complications of stone impaction and also aids the endoscopist when ERCP is performed. At the time of endoscopy, the stent can be seen protruding through the ampulla into the duodenal lumen. The endoscopist can then “cut” over the stent and perform an adequate sphincterotomy with subsequent stone removal (Ponsky et al., 2000).

 

 

B) Common Bile Duct Exploration via Laparoscopic Choledochotomy

       LCBDE is performed when transcystic duct extraction is not appropriate or has failed. The current indications for laparoscopic direct CBD exploration are:

1. Failed transcystic extraction if CBD diameter exceeds 8mm

2. Large single or multiple stones.

3. Unsuccessful attempts at endoscopic stone extraction for large and/or occluding stones (Hanif et al., 2010).

          Once the laparoscopic surgeon has acquired the necessary skills to perform intracorporeal suturing, laparoscopic choledochotomy can be completed successfully. The surgeon must have an adequate cholangiogram prior to making the choledochotomy. Function of pre-exploration cholangiogram:

1. Confirm presence, size, location, and number of stones.

2. Demonstrate anatomic relationships and diameter of the extrahepatic bile duct.

3. Exclude unsuspected pathology, such as cholangiocarcinoma, in jaundiced patients (Rhodes et al., 1995).

            The CBD is exposed anteriorly by opening the peritoneum parallel to the duct. Bile may then be aspirated from the duct to assure it is identified correctly and two stay sutures can be placed for additional retraction. The duct is then carefully entered in the middle along the vertical axis and an opening created for approximately 1.5 to 2.0 cm. The duct is then irrigated with the use or a l4 Fr red rubber catheter passed through a lateral 5 mm trocar. This will typically flush the majority or the CBD stones. A guide wire is then passed into the duodenum under fluoroscopic guidance followed by a balloon catheter. The catheter is then passed up and down the duct to clear any additional stones. Finally a choledochoscope is passed into the duct and duodenum to assure no stones remain (Chand et al., 2006).

 

Biliary drainage after LCBDE:

             Although some advocate primary closure without decompression of the extrahepatic biliary tract, many authors feel this is inadvisable for two reasons. First, manipulations at the lower end of the CBD frequently cause periampullary edema, increasing the risk of bile leakage through the sutured choledochotomy. Second, primary closure precludes completion or postoperative cholangiography (Cuschieri 2006).

A)  T-tube or transcystic tube drainage

          Drainage may be accomplished by placement of a T-tube or by placement of a drainage catheter through the cystic duct. Both are acceptable, A T-tube is the placed into the choledochotomy and absorbable sutures are placed around the opening to secure the tube and prevent bile leak. A finishing cholangiogram is then obtained through the T-tube to demonstrate no filling defects and no leak from the choledochotomy (Cuschieri A 2006).

             However, the insertion of a T-tube is not without complication and the patients have to carry it for several weeks before removal. Morbidity rates related to T-tube presence have been reported to be at a rate of 4% to 16.4%. The T-tube-related complications include accidental T-tube displacement leading to CBD obstruction, bile leakage, persistent biliary fistulas and excoriation of the skin, cholangitis from exogenous sources through the T-tube, and dehydration and saline depletion. Additionally, CBD stenosis has been reported as a long-term complication after T-tube removal. After discharge, indwelling T-tubes become uncomfortable, requiring continuous management, thus restricting patient activity because of the risk of dislodgement (El-geidie 2010).

B)   Primary closure

  In a recent randomized study it was demonstrated that primary closure without external drainage after laparoscopic choledochotomy is feasible and is as safe as T-tube insertion (Zhang et al., 2009).

          Another study was carried out in Gastroenterology Surgery Center in Mansoura University. According to the results of this randomized study, primary closure did not increase the risk of bile leakage after the operation. Postoperative hospital stay and operation time were shorter and the hospital expenses were lower in the primary closure group than in the T-tube group. Additionally, with primary closure, T-tube-related complications could definitely be avoided. Primary closure without external drainage after laparoscopic choledochotomy is feasible, safe, and cost-effective. After verification of ductal clearance, CBD can be closed primarily without the use of T-tube (El-geidie 2010).

            A recent meta-analysis carried out by Zhu et al. tended to favor primary closure over T-tube drainage in the prevention of the development of post-operative complications and confirmed the safety and feasibility of primary closure after choledochotomy for choledocholithiasis. In effect, primary closure avoids the disadvantages associated with the use of T-tube, including significant discomfort, inconvenience to take along and longer hospital stay (Zhu et al., 2011).

C)  Internal drainage

     Other authors advocate insertion of a pigtail stent, which is placed across the lower choledochal sphincter before suture closure of the CBD incision (tubeless choledochotomy). The stent is removed 4 to 6 weeks later by means of upper gastrointestinal endoscopy. This approach seems to be reasonable except that it does not allow a postoperative contrast study (Overby et al., 2010).

   D) Choledochoduodenostomy

             Choledochoduodenostomy (CDD) is indicated in patients with recurrent stones requiring repeated interventions, impacted or giant stones (> 2cm), biliary sludge, and ampullary stenosis. The funnel syndrome in which a distal bile duct stenosis exists in the presence of common bile duct stones is one of the most classic indications for CDD. Most of the common bile duct stones in this situation are primary biliary stones forming as a result of biliary stasis (Aretxabala et al., 1998).

               CDD is carried out after completion of the ductal stone clearance by one of two techniques: side-to-side or end-to- side anastomosis between the CBD and the first part of the duodenum. Some authors advocate for end-to-side CDD, primarily because it avoids the sump syndrome which is caused by food and debris accumulating between the stoma and the papilla of Vater. This leads to contamination of the large and small bile ducts with resulting recurrent cholangitis and even secondary biliary cirrhosis (Aretxabala et al., 1998). End-to-side CDD is also technically easier to perform laparoscopically. The laparoscopic procedure entails transection of the lower end of the CBD just above its entry into the pancreatic parenchyma. The distal end is then closed with a continuous suture and the proximal end anastomosed to the first part of the duodenum using a continuous posterior layer (3/0 absorbable) an interrupted suture for the anterior wall. A drain is left and placed close to the completed anastomosis (Cuschieri A 2006).

           Post-operative complications following Biliary-enteric anastomosis (BEA) including anastomotic leak, hemorrhage, wound infection, intra abdominal abscess/biloma and stricture formation have been reported (Tocchi et al., 2001). These complications are sometimes serious enough to warrant a repeat surgery and at times result in serious long-term morbidity (Parrilla et al., 1991). CDD has a long-term risk of cholangitis that ranges from 0% to 12%; this complication is usually associated with stricture formation at the anastomosis. Stricture may be minimized by performing a mucosa-to-mucosa anastomosis of at least 14 mm in length (Colletti 2006).

Results of Laparoscopic maneuvers in management of CBD stones

       LCBDE is a feasible, safe and effective procedure that carries a low morbidity and mortality. TC-CBDE in conjunction with laparoscopic cholecystectomy will clear the CBD stones in 75% to 100% of all patients, thus reducing the hospital stay and any subsequent endoscopic procedures. Laparoscopic choledochotomy carries a greater morbidity and mortality compared with TC-CBDE and also requires advanced laparoscopic suturing skills. Furthermore, there is a theoretical risk of CBD stricture during suturing of the choledochotomy                                                                                                                 (Memon et al., 2000).

       Thousands of successful LCBDEs have been reported since the introduction of laparoscopic cholecystectomy in the late 1980s. During this time, techniques have evolved that enhance the likelihood of success of the procedure. In experienced hands, successful ductal clearance rates exceed 90%. Morbidity rates have been low in these series. Mortality has occurred in less than 1% of patients (Petelin et al., 2004).

Access Route:

          Most laparoscopic surgeons have generally preferred the transcystic route for ductal exploration when it is feasible. In most series, it is successful in 80% to 90% of cases. In some authors' experience the type and size of the ductal stones dictate the need for a TC-CBDE approach in approximately 90% of cases. As discussed previously, there are well-defined criteria that should lead a surgeon to one or the other approach (Petelin et al., 2004).

Operative Times:

          Laparoscopic choledocholithotomy takes longer than straightforward laparoscopic cholecystectomy. The mean operative time (in minutes) for some of the larger series ranged from 110 to 219. Assuming that mean operative time for laparoscopic cholecystectomy is less than 1 hour, it appears that LCBDE adds approximately 1 hour or more to the procedure time. Interestingly, this added time is not solely because of technical manipulations but includes equipment setup and often the need for additional surgery. It is also noted that these patients are often older, with more chronic changes in the tissues in the porta hepatis, making dissection more difficult (Petelin et al., 2004).

Length of Stay:

          Whereas the length of stay (LOS) for laparoscopic cholecystectomy is generally less than 24 hours, the LOS for patients undergoing LCBDE ranges from 1.3 to 7 days, depending on the severity of the disease, comorbid factors, access route, whether a T-tube was placed, and whether a BEA was created. For TC-CBDE, the mean length of stay is 1.5 days in many large series. LOS for LCBDE via choledochotomy is generally longer than that for the transcystic approach (Petelin et al., 2004).

       The dominant predictor of a prolonged postoperative hospital stay of more than 3 days was the diameter of the CBD measured preoperatively by transabdominal ultrasound. This simply reflected the need for choledochotomy in those patients, but other factors such as concurrent immunosuppression and previous upper abdominal surgery were also significant (Noble et al., 2011).

Complications:

           Morbidity associated with LCBDE occurs in approximately 8% to 10% of patients and includes those problems typically associated with general surgery and laparoscopy: nausea, diarrhea, ileus, ecchymosis, atelectasis, fever, phlebitis, urinary retention, urinary tract infection, wound infection/inflammation, biliary leak, dislodged T-tube, subhepatic fluid collection, pulmonary embolus, and myocardial infarction. It is generally believed that the incidence of complications is less with a laparoscopic approach than an open approach to CBD stones.  Mortality associated with LCBDE is 0% to 1% in the hands of experienced laparoscopic biliary tract surgeons. This incidence is similar to that found in open surgery and relates more to the general health status of these patients than to LCBDE (Petelin et al., 2004).

Predictors of poor postoperative outcomes of LCBDE:

       A study by Noble et al. was designed to determine the predictors of poor postoperative outcomes. It found that LCBDE is well tolerated, with 83.5% of the patients in this series having only minor or no postoperative complications. It is safe and effective after failed endoscopic intervention. Increasing age, and, to a lesser extent, jaundice were the dominant factors found to predict an adverse outcome. Whether patients in these circumstances would be better served by the alternative approach of endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy needs further clarification (Noble et al., 2011).

Go to Chapter 9