Laparoscopic common bile duct exploration: evolution of a new technique

Laparoscopic exploration of the common bile duct (CBD) with a choledochoscope or a stone basket during laparoscopic cholecystectomy was attempted in 60 patients and was successful in 56. The cystic duct was used for entry to the CBD in 46 patients and in 14 a choledochotomy was performed. Of 51 patients with confirmed common duct stones, 38 had complete laparoscopic clearance (75 per cent). In 13 patients the duct was not cleared or was only partially cleared, of whom four went on to have clearance by postoperative percutaneous choledochoscopy down a cystic duct or T-tube track. Two patients with cystic duct tubes passed their remaining stones spontaneously. One patient had open exploration and six required endoscopic retrograde cholangiopancreatography. Of nine patients without stones, choledochoscopy was impossible in three patients whose cholangiogram was later considered to be normal. In five patients stones were excluded by choledochoscopy and in one patient laparoscopic choledochoscopy was undertaken to better define abnormal biliary anatomy; this helped to avoid major bile duct injury. Choledochoscopy was easier with the smaller 3.6-mm ureteroscope but stone removal was more difficult when the basket was too small for the stones, the cystic duct too small relative to stone size or the number of stones was too great. Successful stone clearance was proportional to the level of effort expended, and was limited by operating time and equipment.