The most common biliary tract procedure currently performed is the laparoscopic cholecystectomy. This has yielded interest in management of common bile duct (CBD) stones encountered during the procedure. Successful management of such stones during a laparoscopic cholecystectomy is beneficial to the patient by preventing a secondary or more invasive procedure to clear the duct, such as endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic CBD exploration, respectively. Furthermore, an all-inclusive operation may be more cost-effective. Other operations on the biliary tract, including bile duct resections and reconstructions can be the most technically demanding procedures that a general surgeon performs. The advancement of technology and surgical skills in the field of minimally invasive surgery has allowed for traditionally open complex biliary procedures to be attempted and successfully performed laparoscopically. This chapter focuses on minimally invasive techniques in the management of biliary tract disease. Identification and management of CBD stones and performing biliary bypass procedures are discussed in detail. Highly advanced laparoscopic biliary tract procedures that are performed in selected patients are briefly mentioned as well. These procedures have not gained widespread use and are generally performed by specialized laparoscopic surgeons due to the inherent technical difficulties and there are viable endoscopic therapies that are just as effective as the surgical therapies. Nevertheless, the knowledge and utility of these techniques will be important in practices where advanced endoscopic procedures are not available and at centers specialized in hepatobiliary surgery.
Common bile duct stones are present in as much as 10% of patients with cholelithiasis. The large majority of these stones are less than 4 mm and generally pass into the duodenum without any clinical consequence.1 Nevertheless, stones greater than 3–4 mm should be removed since they may cause severe complications such as pancreatitis and/or cholangitis. Cholangiography and ERCP are the standards by which the CBD is evaluated for the presence of stones. Cystic duct cholangiography can be accomplished in 90% of patients and, overall, the intraoperative cholangiogram (IOC) has a sensitivity of 87% and specificity of more than 95% for the detection of stones.2 As it was in the era of open cholecystectomy, the use of IOC during laparoscopic cholecystectomy remains somewhat controversial. Those that support the routine use of IOC cite this practice (1) to clarify anatomy and therefore reduce bile duct injuries during laparoscopic cholecystectomies; and (2) to detect asymptomatic bile duct stones, which may be present in 5–10% of patients undergoing laparoscopic cholecystectomies. The disadvantages of routine IOC are (1) that it prolongs operative time and (2) false-positive results may lead to unnecessary procedures (~50% of patients with incidental CBD stones found at time of surgery will not need any intervention).3,4 Presently, the literature suggests that there is no difference in major and minor bile duct injuries whether routine or selective IOC are performed.2,5–7 Additionally, a large number of routine IOCs have to be performed, compared to a selective approach, to detect missed CBD injuries or retained CBD stones ...