Strategy and technique of laparoscopic common bile duct exploration

The laparoscopic approach to common bile duct exploration enables the complete clearance of stones from the bile duct without damage to structures of physiological importance such as the ampulla of Vater. Despite preoperative endoscopic retrograde cannulation of the biliary tree (ERCP) in patients with suspected stones, routine intraoperative cholangiography reveals a further 6% with unsuspected common bile duct stones. Both the preoperative suspected stone and the stone found on intraoperative cholangiography can be adequately managed by the laparoscopic method. The approach to the common bile duct via the cystic duct avoids incising the common duct or the sphincter of Oddi. The common bile duct can be approached satisfactorily by balloon dilatation of the cystic duct to 5 mm so enabling the choledochoscope to be inserted into the common bile duct. Small stones are washed into the duodenum or extracted by the Segura basket retrogradely through the cystic duct. Larger stones can be disintegrated by laser or electrohydraulic lithotripsy; the fragments can either be washed into the duodenum or sucked out via the cystic duct. Laparoscopic choledochotomy is indicated for multiple big or proximally located stones. The larger sized Segura basket can be used effectively for these large stones. Residual stones are extracted under cholangioscopic control and any incarcerated stone disintegrated by lithotripsy. A small catheter placed in the common bile duct or a standard T-tube completes the exploration and avoids disordered function of the sphincter of Oddi.(ABSTRACT TRUNCATED AT 250 WORDS)