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INDICATIONS

Laparoscopic common bile duct (CBD) exploration (LCBDE) is indicated for all patients with known CBD stones at the time of laparoscopic cholecystectomy, but is most commonly used when an intraoperative cholangiogram or ultrasound exam demonstrates one or more filling defects in the CBD, presumed to be CBD stones. Following cholecystectomy, most CBD stones are addressed with endoscopic retrograde cholangiography and endoscopic sphincterotomy (ERC/ES) rather than LCBDE. Additionally, in the presence of acute cholangitis or acute pancreatitis from choledocholithiasis, ERC/ES has proven to be a safer strategy that open CBDE. Although no studies have randomized patients with acute cholangitis to LCBDE or ERC/ES, the benefits of urgent bile duct decompression can usually be achieved with an ERC/ES, followed by laparoscopic cholecystectomy (if not already performed) at a later date, when the acute illness has resolved.

Contraindications to LCBDE are few. In patients with an impacted stone, LCBDE may fail, requiring the placement of a T tube, followed by ERC/ES or a hybrid radiologic and endoscopic procedure. Additionally, the patient with portal vein thrombosis or other etiologies of portal hypertension may have extensive venous collateralization in the porta hepatis, making choledochotomy to remove stones very hazardous.

PATIENT PREPARATION

LCBDE is performed as an adjunct to laparoscopic cholecystectomy in all but a few rare situations. The patient position and room setup are identical to those for laparoscopic cholecystectomy (Figure 1A). The fundus of the gallbladder remains elevated at the time of cholangiography and bile duct exploration (Figure 1B). The most important aspects of preparation are ensuring that the patient is on a fluoroscopy table, which will allow the C-arm to get under the patient without running into the table supporting column (Figure 1C). The second most important aspect of preparation is ensuring that a cart containing all LCBE equipment is close at hand.

Items necessary on the LCBDE cart include an endoscopic light source (for the choledochoscope), an endoscopic video camera, and an additional monitor if these items are not built into the room where laparoscopic cholecystectomy is being done. The central item for LCBDE is the 3- to 3.5-mm (diameter) flexible choledochoscope, kept sterile on the CBDE cart. The cart should have, at a minimum, the following items: hydrophilic guidewires (100 cm, 0.035-in. diameter), disposable scope introduction sheaths, 8-mm dilating balloons (for the cystic duct), 2.8 French flat wire baskets, and T tubes that can be placed over a guidewire. Helical stone baskets (3–4 French) with filiform tips are useful if fluoroscopic bile duct exploration is to be attempted instead of endoscopic choledochoscopy. Access to an electrohydraulic lithotripsy unit is valuable for the rare occasion where impacted stones cannot be dislodged.

OPERATIVE PROCEDURE

LCBDE may be done through the cystic duct with ...

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