JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 1, Number 5, 1991 Mary Ann Liebert, Inc., Publishers
Laparoscopic Common Bile Duct Exploration MARK E. STOKER, M.D., RAYMOND J. LEVEILLEE, M.D., JAMES C. McCANN, Jr., M.D., F.A.C.S., and BALTEJ S. MAINI, M.D., F.A.C.S.
ABSTRACT
Operative common bile duct exploration, performed in conjunction with cholecystectomy, has been considered the treatment of choice for choledocholithiasis in the presence of an intact gallbladder. With the advent of laparoscopic cholecystectomy, the management of common bile duct stones has been affected. More emphasis is being placed on endoscopie sphincterotomy and options other than operative common duct exploration. Because of this increasing demand, we have developed a new technique for laparoscopic common bile duct exploration performed in the same operative setting as laparoscopic cholecystectomy. A series of five patients who successfully underwent common bile duct exploration, flexible choledochoscopy with stone extraction, and T-tube drainage, all using laparoscopic technique, is reported. Mean postoperative length of hospital stay was 4.6 days. Outpatient T-tube cholangiography was performed in all cases and revealed normal ductal anatomy with no retained stones. Follow-up ranged from 6 weeks to 4 months,and all patients were asymptomatic and had normal liver function tests.
INTRODUCTION years, laparoscopic cholecystectomy has rapidly emerged as an important for the treatment of gallstone disease. Since the first laparoscopic cholecystectomy by Mouret in procedure has gained in popularity faster than perhaps any other new technique in surgery. However, the evolution of this technology has brought new dilemmas, prominent among them being the management of bile duct calculi. A logical algorithm for the treatment of common duct stones has been proposed by several authors.1'2 If common bile duct stones are suspected or documented, a preoperative endoscopie papillotomy with stone extraction is performed. A postoperative endoscopie papillotomy and stone extraction can be performed if stones are found on intraoperative cholangiography. Other modalities include extracorporeal lithotripsy and contact chemodissolution agents.3"6 The intraoperative use of an
Over technique 1987,' the the,
past several
Division of General and Vascular Surgery, The Fallón Clinic, and St. Vincent Hospital, and the Department of Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts.
287
STOKER ET AL. ultrathin
(2-3 mm) flexible choledochoscope introduced via the cystic duct in conjunction with laser
lithotripsy is another option.1'7 The following is a description of a new laparoscopic technique for common bile duct exploration which includes flexible choledochoscopy with stone extraction and T-tube drainage of the choledochus, all performed successfully on a series of 5 patients.
MATERIALS AND METHODS Five patients underwent laparoscopic common bile duct exploration during the period from September to November 1990. Their age range was 14-79 years. The first two patients had unsuccessful attempts at endoscopie sphincterotomy. Three patients had unsuspected common duct calculi disocvered at the time of laparoscopic cholecystectomy by intraoperative cholangiography. In all cases the gallbladder was intact. Two patients (pt. 1&4) had previous abdominal surgery (See Table 1.)
Surgical technique is placed in the supine position and administered general anesthesia. The urinary bladder is and a nasogastric tube placed, after which the patient is placed in a slight Trendelenburg catheterized, position. Pneumoperitoneum is established in either a percutaneous fashion with the Veress needle, or with an open technique via an infraumbilical 1 cm incision using the Hasson trocar and cannula (Week Instrument Co., Princeton, NJ). A 10 mm zero degree laparoscope with video camera attachment is inserted into the umbilical sheath, and the peritoneal contents are visualized. The patient is then placed into a reverse Trendelenburg position and the right side is slightly elevated. Three additional trocars, one in the epigastrium, one in the right midclavicular line, and one in the anterior axillary line approximately 2 cm below the costal then The duct and identified and dissected free using laparoscopic are are cystic artery 1). margin, placed (Fig. surgical instruments. A cholangiogram is obtained via the cystic duct with a #4 French cholangiogram catheter. The cystic duct and artery are then ligated with titanium clips and divided. The gallbladder is left in situ to aid in the anterior and superior retraction of the liver and thereby facilitate exposure of the common bile duct. The anterior surface of the common bile duct is dissected free of its parietal peritoneal attachments. Minute vessels on the surface of the duct are easily visualized and carefully coagulated with electrocautery. A longitudinal incision is made in the common bile duct with the microscissors. Bile cultures are obtained via a suction instrument. A fifth trocar and sheath (5 mm) are introduced between the midclavicular and midline sheaths, just below the costal margin (Fig. 1). The Olympus CHF-P20 flexible choledochoscope (Olympus Corporation, Lake Success, NY), with an outside diameter of 4.9 mm is introduced into the sheath and directed into the lumen of the common duct enterotomy under laparoscopic visualization (Fig. 2). Using the flexible choledochoscope in conjunction with a stone basket, irrigating solution, and balloon embolectomy catheter, the common bile duct is explored and cleared of all calculi. A French #18 T-tube is cut to length and delivered into the peritoneal cavity and manipulated via the choledochotomy into the common bile duct. The long end of the T-tube is brought out of the abdominal wall via the sheath used for the choledochoscope. The choledochotomy is closed around the T-tube using 4-0 PDS suture (Ethicon Inc., Somerville, NJ) on a small Keith's needle designed for laparoscopic use. Knots are tied with an intraperitoneal instrument tie technique. The gallbladder is dissected from the liver bed and removed from the abdomen using standard laparoscopic cholecystectomy techniques.',2'8 A closed suction drain is placed into Morrison's pouch and brought out through the lateralmost sheath. Postexploratory cholangiography is performed to document both the absence of retained stones and the proper position of the T-tube without extravasation of contrast. The closed suction drain placed in Morrison's pouch is removed within the first 48 hours if there is no evidence of bile extravasation. T-tube cholangiograms can be performed at any point in the postoperative period, either during the same hospitalization or as an outpatient procedure. Our standard practice is to remove the T-tube in 2-3 weeks, once a normal postoperative T-tube cholangiogram has been obtained. The
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LAPAROSCOPIC COMMON BILE DUCT EXPLORATION
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Laparoscopic Common Bile Duct Exploration MARK E. STOKER, M.D., RAYMOND J. LEVEILLEE, M.D., JAMES C. McCANN, Jr., M.D., F.A.C.S., and BALTEJ S. MAINI, M.D., F.A.C.S.
ABSTRACT
Operative common bile duct exploration, performed in conjunction with cholecystectomy, has been considered the treatment of choice for choledocholithiasis in the presence of an intact gallbladder. With the advent of laparoscopic cholecystectomy, the management of common bile duct stones has been affected. More emphasis is being placed on endoscopie sphincterotomy and options other than operative common duct exploration. Because of this increasing demand, we have developed a new technique for laparoscopic common bile duct exploration performed in the same operative setting as laparoscopic cholecystectomy. A series of five patients who successfully underwent common bile duct exploration, flexible choledochoscopy with stone extraction, and T-tube drainage, all using laparoscopic technique, is reported. Mean postoperative length of hospital stay was 4.6 days. Outpatient T-tube cholangiography was performed in all cases and revealed normal ductal anatomy with no retained stones. Follow-up ranged from 6 weeks to 4 months,and all patients were asymptomatic and had normal liver function tests.
INTRODUCTION years, laparoscopic cholecystectomy has rapidly emerged as an important for the treatment of gallstone disease. Since the first laparoscopic cholecystectomy by Mouret in procedure has gained in popularity faster than perhaps any other new technique in surgery. However, the evolution of this technology has brought new dilemmas, prominent among them being the management of bile duct calculi. A logical algorithm for the treatment of common duct stones has been proposed by several authors.1'2 If common bile duct stones are suspected or documented, a preoperative endoscopie papillotomy with stone extraction is performed. A postoperative endoscopie papillotomy and stone extraction can be performed if stones are found on intraoperative cholangiography. Other modalities include extracorporeal lithotripsy and contact chemodissolution agents.3"6 The intraoperative use of an
Over technique 1987,' the the,
past several
Division of General and Vascular Surgery, The Fallón Clinic, and St. Vincent Hospital, and the Department of Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts.
287
STOKER ET AL. ultrathin
(2-3 mm) flexible choledochoscope introduced via the cystic duct in conjunction with laser
lithotripsy is another option.1'7 The following is a description of a new laparoscopic technique for common bile duct exploration which includes flexible choledochoscopy with stone extraction and T-tube drainage of the choledochus, all performed successfully on a series of 5 patients.
MATERIALS AND METHODS Five patients underwent laparoscopic common bile duct exploration during the period from September to November 1990. Their age range was 14-79 years. The first two patients had unsuccessful attempts at endoscopie sphincterotomy. Three patients had unsuspected common duct calculi disocvered at the time of laparoscopic cholecystectomy by intraoperative cholangiography. In all cases the gallbladder was intact. Two patients (pt. 1&4) had previous abdominal surgery (See Table 1.)
Surgical technique is placed in the supine position and administered general anesthesia. The urinary bladder is and a nasogastric tube placed, after which the patient is placed in a slight Trendelenburg catheterized, position. Pneumoperitoneum is established in either a percutaneous fashion with the Veress needle, or with an open technique via an infraumbilical 1 cm incision using the Hasson trocar and cannula (Week Instrument Co., Princeton, NJ). A 10 mm zero degree laparoscope with video camera attachment is inserted into the umbilical sheath, and the peritoneal contents are visualized. The patient is then placed into a reverse Trendelenburg position and the right side is slightly elevated. Three additional trocars, one in the epigastrium, one in the right midclavicular line, and one in the anterior axillary line approximately 2 cm below the costal then The duct and identified and dissected free using laparoscopic are are cystic artery 1). margin, placed (Fig. surgical instruments. A cholangiogram is obtained via the cystic duct with a #4 French cholangiogram catheter. The cystic duct and artery are then ligated with titanium clips and divided. The gallbladder is left in situ to aid in the anterior and superior retraction of the liver and thereby facilitate exposure of the common bile duct. The anterior surface of the common bile duct is dissected free of its parietal peritoneal attachments. Minute vessels on the surface of the duct are easily visualized and carefully coagulated with electrocautery. A longitudinal incision is made in the common bile duct with the microscissors. Bile cultures are obtained via a suction instrument. A fifth trocar and sheath (5 mm) are introduced between the midclavicular and midline sheaths, just below the costal margin (Fig. 1). The Olympus CHF-P20 flexible choledochoscope (Olympus Corporation, Lake Success, NY), with an outside diameter of 4.9 mm is introduced into the sheath and directed into the lumen of the common duct enterotomy under laparoscopic visualization (Fig. 2). Using the flexible choledochoscope in conjunction with a stone basket, irrigating solution, and balloon embolectomy catheter, the common bile duct is explored and cleared of all calculi. A French #18 T-tube is cut to length and delivered into the peritoneal cavity and manipulated via the choledochotomy into the common bile duct. The long end of the T-tube is brought out of the abdominal wall via the sheath used for the choledochoscope. The choledochotomy is closed around the T-tube using 4-0 PDS suture (Ethicon Inc., Somerville, NJ) on a small Keith's needle designed for laparoscopic use. Knots are tied with an intraperitoneal instrument tie technique. The gallbladder is dissected from the liver bed and removed from the abdomen using standard laparoscopic cholecystectomy techniques.',2'8 A closed suction drain is placed into Morrison's pouch and brought out through the lateralmost sheath. Postexploratory cholangiography is performed to document both the absence of retained stones and the proper position of the T-tube without extravasation of contrast. The closed suction drain placed in Morrison's pouch is removed within the first 48 hours if there is no evidence of bile extravasation. T-tube cholangiograms can be performed at any point in the postoperative period, either during the same hospitalization or as an outpatient procedure. Our standard practice is to remove the T-tube in 2-3 weeks, once a normal postoperative T-tube cholangiogram has been obtained. The
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