Intraoperative flexible choledochoscopy for intrahepatic and extrahepatic biliary calculi

This prospective study evaluates the use of intraoperative flexible choledochoscopy in the detection and removal of additional stones after conventional bile duct exploration. The biliary system of 109 patients was examined with an Olympus CHF-B4 choledochoscope after conventional methods of exploration. Sixty-five patients had only common duct stones and 44 patients had intrahepatic stones with or without stones in the common duct. Additional stones were detected in 11 patients (16.9%) in the group with common duct stones; eight of these patients had their stones completely removed. Unsuspected residual stones were discovered by means of postoperative cholangiography in three more patients (4.6%); thus the total number of patients with residual stones was six (9.2%). Additional stones were detected in 39 patients (88.6%) in the group with intrahepatic stones. Of these, only 13 patients managed to be freed of stones with the use of the choledochoscope. A further 10 patients underwent liver resection to achieve stone clearance. Unsuspected retained stones were found postoperatively in seven of the 28 patients (25%) whose biliary systems were considered clear of stones. The overall number of patients with retained stones in the group with intrahepatic stones was 23 (52.3%). We concluded that intraoperative flexible choledochoscopy is useful in detecting intrahepatic stones left behind after conventional exploration. However, complete removal of the stones is difficult to achieve.