Laparoscopic common bile duct stone clearance with flexible choledochoscopy

Area of Science:

• Minimally Invasive Surgery
• Gastroenterology
• Hepatobiliary Surgery

Background:

• Laparoscopic common bile duct exploration (LCBDE) is a viable alternative to ERCP for bile duct stone removal.
• Current guidelines lack clarity on optimal LCBDE approaches, including trans-cystic vs. choledochotomy and the use of flexible choledochoscopy (FCD) or intraoperative cholangiography (IOC).

Purpose of the Study:

• To evaluate the safety, efficacy, and outcomes of LCBDE in patients with common bile duct stones (CBDS).
• To compare the trans-cystic approach with choledochotomy for LCBDE.
• To assess the utility of flexible choledochoscopy (FCD) versus intraoperative cholangiography (IOC) in guiding LCBDE.

Main Methods:

• A prospective, non-randomized study of 113 patients undergoing laparoscopic cholecystectomy with LCBDE for CBDS.
• Patients were stratified by age, comorbidity, and surgical approach (trans-cystic vs. choledochotomy).
• The use of FCD or IOC for guidance during LCBDE was recorded.

Main Results:

• LCBDE achieved a 91.8% success rate in stone clearance with no mortality.
• The trans-cystic approach resulted in a shorter hospital stay (median 2 days) compared to choledochotomy (median 6 days).
• Flexible choledochoscopy (mean surgery time 75 min) was associated with shorter operative times than IOC guidance (mean 107 min).

Conclusions:

• Laparoscopic cholecystectomy combined with LCBDE is a safe and highly effective procedure for bile duct stone removal.
• The trans-cystic approach is suitable for the majority of patients, while choledochotomy should be reserved for large stones.
• Flexible choledochoscopy is the preferred method for guiding LCBDE due to its efficiency.