Laparoscopic common bile duct exploration

As is pointed out in multiple publications, laparoscopic cholecystectomy has rapidly gained recognition an acceptance in the management of chronic cholecystitis and most cases of acute cholecystitis.A low incidence of complications accompanies laparoscopic cholecystectomy now that experience has been gained with this procedure by laparoscopically skilled surgeons.v-» However, the management of stones found or suspected in the common bile duct continues to be controversial. The gold standard for treatment of choledocholisthiasis remains the open exploration of the bile ducts with a reported mortality of 0.3%-0.19% and a rate of retained stones of between 2-4 %. Both surgeons and gastroenterologists skilled in endoscopy have espoused endoscopic retrograde cholangiopanreatography and sphincterotomy (ERCP/ES) preoperatively or postoperatively for the treatment of known common bile duct stones This approach adds additional procedures and potentially compounds the complications of the separate operative interventions to deal with the diseased gallbladder and to clear the common bile duct of obstruction. In several series of patients the morbidity of endoscopic sphincterotomy has ranged from 9-16%, with bleeding, acute pancreatitis, acute cholangitis, residual stones, duodenal perforation, and common bile duct perforation the leading causes of complications. There continues to be an incidence of retained stones of 9.1-14.7% with ERCP/ES.Furthermore, as high as 86% of indiscriminate preoperative ERCP studies show no evidence of stones in the common bile duct, making this an unnecessary intervention in such cases. There has been no consistent reduction in subsequent mortality in complicated biliary cases by the use of ERCP/ES alone, even with the gallbladder left in situ.