Laparoscopic common bile duct exploration after failed endoscopic stone extraction

Despite the documented success rate and safety of laparoscopic ductal stone extraction, the majority of patients are treated with preoperative endoscopic stone extraction followed by laparoscopic cholecystectomy. When this fails, conventional open cholecystectomy and common bile duct exploration are performed. We report here a series of patients who were treated laparoscopically after failed attempts at endoscopic stone extraction.

Nineteen patients (12 women and seven men, aged 41-96 years) were treated laparoscopically. Four had undergone previous cholecystectomy. ERCP had been attempted in all patients, was unsuccessful in three patients, and had been interpreted as normal in two. Endoscopic stone extraction had been attempted in 14 patients. The mean follow-up period was 23 months, range 1-54 months.

Ductal calculi were confirmed in 18 patients with successful and complete laparoscopic ductal clearance in 15 (83%), two of whom underwent an additional laparoscopic choledochoduodenostomy due to a large stone load and a grossly dilated common bile duct. Conversion to open surgery was required in three cases (17%). Ductal clearance at a single operation was achieved in all 18 patients. There were no postoperative deaths, but two patients developed postoperative complications (11% morbidity), one requiring laparotomy. The median postoperative hospital stay was five days, range 4-41 days. Recurrence of calculi was encountered in one patient.

Laparoscopic ductal stone clearance after failed endoscopic stone extraction is successful in the majority of patients, and should be attempted prior to recourse to open surgery, provided the necessary laparoscopic biliary expertise is available.