REVIEW ARTICLE


https://doi.org/10.5005/jp-journals-10030-1395
Panamerican Journal of Trauma, Critical Care & Emergency Surgery
Volume 11 | Issue 3 | Year 2022

Laparoscopic Common Bile Duct Exploration for the Acute Care Surgeon


Elise A Biesboer1https://orcid.org/0000-0002-7639-1955, Patrick B Murphy2https://orcid.org/0000-0002-6086-8966

1,2Department of Trauma and Acute Care Surgery, Division of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America

Corresponding Author: Patrick B Murphy, Department of Trauma and Acute Care Surgery, Division of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America, Phone: 414-955-1728, e-mail: pbatesmurphy@gmail.com

Received on: 16 September 2022; Accepted on: 09 October 2022; Published on: 31 December 2022

ABSTRACT

Aim: To provide the acute care surgeon with an overview, technical description, and discussion of the benefits of laparoscopic common bile duct exploration to promote surgically focused care of gallstone disease.

Background: Gallstone disease is one of the most common surgical conditions worldwide. Choledocholithiasis imparts specific management concerns and challenges. Currently, most suspected choledocholithiasis is managed via a two-stage approach by clearing the biliary tree preoperatively, followed by laparoscopic cholecystectomy (LC). Laparoscopic common bile duct exploration (LCBDE) is an attractive, one-stage surgical approach to manage choledocholithiasis; however, it has become a lost skill for modern surgeons. Transcystic (TC) LCBDE has been shown to be as successful as alternative methods and offers a low complication rate and short length of hospital stay.

Clinical significance: Although most surgeons do not currently perform LCBDE, surgically focused care of choledocholithiasis promotes improved patient care through a single anesthetic and low complication rate. Surgeons and hospital systems also benefit from increased surgical expertise, shorter length of hospital stay, and potentially decreased costs.

Conclusion: Surgeons and systems should focus on shifting the balance toward surgically based care for the management of suspected and confirmed choledocholithiasis. The review focuses on strategies to promote a surgery-first approach to choledocholithiasis.

How to cite this article: Biesboer EA, Murphy PB. Laparoscopic Common Bile Duct Exploration for the Acute Care Surgeon. Panam J Trauma Crit Care Emerg Surg 2022;11(3):156-162.

Source of support: Nil

Conflict of interest: None

Keywords: Choledocholithiasis, Laparoscopic common bile duct exploration, Review article, Transcystic.

INTRODUCTION

Gallstone disease is one of the most common surgical disorders in the United States of America. It is estimated that gallstones affect over 20 million Americans nationwide.1 Most people with gallstones are asymptomatic; however, gallstones may become symptomatic and present with abdominal pain, fevers, nausea, or vomiting. Choledocholithiasis is present in upwards of 10% of patients who have symptomatic gallstones,2 and there are approximately 26,000 inpatient admissions each year for choledocholithiasis in the United States of America.3 Patients with choledocholithiasis may have additional lab findings, including elevated liver enzymes or hyperbilirubinemia.

Timely identification and treatment of choledocholithiasis is critical as common or hepatic bile duct stones can lead to complications of pancreatitis and cholangitis. Gallstone pancreatitis is diagnosed by clinical signs of pancreatitis, including epigastric abdominal pain, elevated lipase, and the presence of gallstones and pancreatic inflammation on cross-sectional or ultrasound imaging. Cholangitis occurs when blockage of biliary drainage via the common bile duct (CBD) causes infection with the clinical constellation of fever, right upper quadrant pain, and jaundice, known as Charcot’s triad. More severe disease is defined by Reynolds pentad as fever, right upper quadrant pain, jaundice, hypotension, and altered mental status.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has developed an algorithm to preoperatively stratify patients into low, intermediate, and high risk of choledocholithiasis based on their clinical, lab, and imaging findings.4 The American Society for Gastrointestinal Endoscopy has also developed guidelines regarding the use of magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, and surgery in the diagnosis and management of choledocholithiasis.5 Despite these guidelines, institutional adherence to recommended workup and treatment is quite variable.6

A direct to surgery approach offers an attractive one-step approach to gallstone disease in which choledocholithiasis can be identified and managed in a minimally invasive fashion while also removing the source of stones with cholecystectomy. Potential benefits include fewer procedures, shorter lengths of stay, and lower costs of care by avoiding unnecessary tests. The direct to surgery approach should be considered by surgeons managing patients with acute gallstone disease with suspicion of choledocholithiasis. The current editorial will review the historical and modern management of choledocholithiasis and will discuss the strategies to overcome the barriers of a direct to surgery approach for acute care surgeons.

Evolution of the Management of Choledocholithiasis

The management of cholelithiasis and choledocholithiasis has varied substantially over the years and among countries according to advances in technology. Open cholecystectomy and CBD exploration were the standards of care until the 1970’s. The first description of stone extraction from the CBD was from a Swiss surgeon, Ludwig Courvoisier, in 1889.7 Early ERCP was first described by Japanese endoscopists in 1974, where they were able to endoscopically perform a sphincterotomy and extract CBD stones.8 The development of laparoscopy revolutionized the management of both cholelithiasis and choledocholithiasis.Laparoscopy was first introduced in the late 19th century, and in the late 1980’s laparoscopic cholecystectomy (LC) was performed in France.9 After this, minimally invasive techniques for managing choledocholithiasis began to gain popularity, and LCBDE was described shortly after in the early 1990’s.9

Advances in ERCP, as well as the morbidity associated with direct manipulation of the CBD during a more traditional exploration, made endoscopy the preferred approach for the management of choledocholithiasis. The transcystic (TC) approach was first described in the early 1990’s.9,10 It avoids many of the limitations of a more traditional LCBDE, such as CBD stricture or leak, and takes advantage of an already exposed structure, the cystic duct.

Current management options remain varied for choledocholithiasis, and a standard is lacking despite society guidelines.4,6 The possible approaches to a patient with choledocholithiasis include a two-stage approach with preoperative imaging and procedures to clear the biliary system or a single-stage approach with LC, intraoperative cholangiogram (IOC), and possible LCBDE based on IOC findings. Certainly, additional options include open cholecystectomy and open CBDE or even intraoperative on-table ERCP; however, the former has significant morbidity, and the latter is usually fraught with logistical issues in arranging care teams. Overall, after ERCP was developed, it became an increasingly popular way to manage CBD stones in a minimally invasive fashion and is often used in conjunction with MRCP.

Assessment of management practices for choledocholithiasis from 1998 to 2013 has shown that surgical CBD exploration (including open and laparoscopic) has decreased from 39.8% of patients in 1998 to 8.5% of patients in 2013. In 2013, 95% of choledocholithiasis patients had an ERCP, and only 1.5% underwent LCBDE.3 Surgeon preference toward ERCP can be attributed to perceived technical difficulty, the time demands associated with CBDE, and lack of equipment.11,12 This generated concerns that surgical residents were not getting adequate training in CBD exploration.3,13 In fact, according to the 2020–2021 Accreditation Council for Graduate Medical Education Surgery Case Logs National Data Report, surgery residents performed an average of 0.8 LCBDE and 0.7 open CBDE total despite reports of 123 laparoscopic cholecystectomies and seven open cholecystectomies.14

As with any procedure, ERCP has its limitations. The risk of complication is about 7% and includes intestinal perforation, hemorrhage, cholecystitis or cholangitis, and pancreatitis.15 There are also associated risks with an additional anesthetic. Some have suggested that due to the cost and risk, preoperative ERCP is only worthwhile for the diagnosis and management of choledocholithiasis if the probability of having choledocholithiasis is >90%.16 For patients with a lower probability of choledocholithiasis, LC and IOC is the most cost-effective diagnostic strategy.17 Postoperative ERCP carries the risk of cystic stump blowout and subsequent bile leak.18 On the other hand, altered foregut anatomy can preclude the ability of ERCP to reach the biliary system, for example, in the setting of Roux-en-Y gastric bypass. This may necessitate a more invasive approach, such as laparoscopic-assisted ERCP through the remnant stomach. Finally, if MRCP is used for diagnosis prior to ERCP, this may add cost and length of stay to the patient’s treatment.17

Despite not many surgeons performing it, LCBDE overall has demonstrated great success. Even in 1993, technical success rates were reported at 96%, with a 9% complication rate and <1% mortality.9 In comparing single-stage LCBDE and two-stage LC + ERCP, there have been no differences seen in mortality or morbidity.18,19 A meta-analysis of randomized controlled trials showed an overall technical success rate of 88% with LCBDE, which was significantly higher than LC + ERCP. Hospital length of stay was also shorter in the LCBDE arm; however, the total cost was not significantly different in comparing LCBDE and LC + ERCP.18 For these reasons, single-stage LCBDE may be a more attractive option for the surgeon.

Operative Steps

There are two approaches to LCBDE: via the cystic duct (TC) or via the CBD [transductal (TD)], each with its advantages and disadvantages. A TC approach offers numerous benefits compared to incising the CBD, and the cystic duct is readily accessed during LC. Therefore, the TC approach will be the focus (Tables 1 and 2).

Table 1: Additional necessary equipment for LCBDE
Laparoscopic common bile duct exploration additional equipment
Choledochoscope or ureteroscope
Guidewire 0.35 inch × 180 cm with torque device
Power injector tubing with saline
6 mm balloon dilator with pressure inflation device
Additional videoscope
Stone retrieval basket
Introducer sheath
Endoloop
Consider
4–5 French scale (Fr) Fogarty balloon catheters9,14
Table 2: Pros, cons, and relative contraindications for TC versus TD-LCBDE
TC TD
Pros Shorter operative time Better for larger stones
Less risk of bile leak
Shorter hospital length of stay
Avoids drain placement
Cons Can be difficult if cystic duct valves or tortuous duct are present Requires closure of CBD primarily or over T-tube
Drain placement
Risk of stricture
Longer operative time
Longer hospital stay
Relative contradindications Cystic duct <4 mm Non-dilated CBD (<8–10 mm)
CBD stones >6 mm or stone size to cystic duct ratio >1
Multiple stones
Cystic duct entrance anterior on CBD

To prepare for LCBDE, there is additional equipment needed in the operating room aside from the traditional LC equipment. This includes an additional videoscope, a choledochoscope or ureteroscope, a guidewire, a 6 mm balloon dilator, stone retrieval baskets, an introducer sheath, and an endoloop (Table 1). There are commercially available kits with readily available equipment. The most common is from Cook, the Cook Medical CBD Exploration Kit (Cook Medical, Bloomington, Indiana, United States of America). A specialized CBD exploration cart near the operating room is also recommended for easy retrieval of necessary equipment.2 Either a homemade kit or a purchased kit readily available will greatly increase the adoption of the technology.

The TC approach involves the standard approach to a LC with safe entry into the abdomen, dissection of the triangle of Calot, and acquisition of the critical view.20 A cholangiogram is then performed to confirm the presence of CBD stones based on the patient’s preoperative risk stratification. Approaches vary between selective to routine intraoperative cholangiography. Our preferred approach is selective according to SAGES guidelines based on preoperative pretest probability (Fig. 1).4 Multiple techniques are available for IOC, and we recommend surgeons familiarize themselves with at least two approaches. Our general approach is with an Olsen clamp and pediatric feeding tube or cholangiocatheter if the cystic duct anatomy is clear, or a Kumar clamp across the infundibulum of the gallbladder if the anatomy is not clear. A pediatric feeding tube and most cholangiocatheters can fit the appropriate size wire without needing to change instruments should the IOC be positive.

Fig. 1: An acute care surgeon’s approach to workup and treatment of choledocholithiasis. Adapted from the SAGES and American Society for Gastrointestinal Endoscopy guidelines

If filling defects are identified, 1 mg of glucagon is administered intravenously, and flushing of the CBD with 300 cc of injectable 0.9% normal saline is performed to attempt to evacuate smaller stones. If this is unsuccessful, a guidewire is advanced through the cholangiocatheter into the cystic ductotomy, the CBD, and the duodenum under fluoroscopic guidance. This is performed through the midclavicular port, and therefore the surgeon should stand on the right side of the patient (Fig. 2). The introducer sheath is threaded over the guidewire through the trocar to prevent damage to the choledochoscope from the trocar valves and to prevent looping of the scope. If the cystic duct is not sufficiently dilated, the cystic duct can be gently dilated with a 6 mm angioplasty balloon over the guidewire (Fig. 3). A choledochoscope is then advanced over the guidewire into the cystic duct. Saline is continuously flushed via an injector pedal through the choledochoscope to help with this step. An assistant uses a Maryland grasper through the epigastric port to grasp the choledochoscope and assist with insertion into the cystic duct. Often, this can be the most difficult step. Several troubleshooting steps are available, including additional balloon dilation, direct dilation with a Maryland grasper, or further dissection of the cystic duct and a longitudinal ductotomy lower on the duct.

Fig. 2: Suggested operating room setup and positioning for bile duct exploration portion of LCBDE. A, surgical assistant; Anes, anesthesia; S, surgeon; T, surgical tech. Adapted from Puhalla et al. and Helton and Ayloo11,25

Fig. 3: Balloon dilation of the cystic duct. The angioplasty balloon is fed over a wire, which is directed through the cystic duct into the duodenum. An assistant’s Maryland grasper aids insertion of the wire and balloon into the cystic duct

Once the choledochoscope is in the cystic duct, the duct should be continuously irrigated with saline while manipulating the choledochoscope into and through the CBD. The guidewire is then removed. Once the stone(s) is identified, multiple approaches to stone clearance are possible. The simplest is a wire basket, which can be advanced through the working port of the choledochoscope to retrieve the stone under direct visualization. Second, an attempt can be made to push the stone through the papilla with the choledochoscope. Third, advanced techniques such as lithotripsy may be used to break up bigger stones to either push through the papilla or remove them with the wire basket. It is helpful to keep the patient in reverse Trendelenburg position in case stones are displaced into the common hepatic duct as they should follow gravity and drift back into the CBD.11

If there are multiple stones, the above processes must be repeated. If a stone is retrieved using the wire basket technique, the entire choledochoscope must be removed from the duct. Reinsertion of the choledochoscope into the cystic duct may occasionally require rewiring of the duct. We do not routinely replace the wire as the choledochoscope can usually reenter the cystic duct easily following stone removal. Once no further stones have been identified, a completion cholangiogram is performed through the choledochoscope to document clearance. The cystic duct is then ligated with clips or an endoloop if it is enlarged, and the gallbladder is removed from the cystic plate as usual.

Advanced Techniques

Additional, more advanced techniques to improve TC exploration success include laser lithotripsy or fluoroscopic balloon dilation of the sphincter. Some surgeons simply insert a wire basket or balloon catheter into the cystic duct and direct it under fluoroscopic guidance into the CBD to remove stones.2 This may be more useful if a choledochoscope or ureteroscope is not readily available or while the equipment is being prepared.

Laser lithotripsy has successfully managed large CBD stones.21,22 It is recommended to advance the laser 1cm last the tip of the choledochoscope to prevent damage to the scope, aim at the center of the biliary stone, trap the stone against the biliary wall to prevent movement, and after the stone is fragmented attempt to pass the choledochoscope through the papilla to facilitate passage of small debris. 22

One last resort technique is fluoroscopic balloon dilation of the ampulla. A balloon catheter can be inserted into the common duct, inflated, and gently retracted until resistance from the ampulla is felt. The ampulla can be gently dilated to 3–4 mm over 3 minutes to attempt to flush or push stones through.23,24 There may be an additional risk of pancreatitis with this procedure24; however, more recently, choledocholithiasis has been successfully managed with ampullary dilation and without postoperative pancreatitis.23

Transductal Approach

There are a few situations in which TC exploration may not be feasible, including a cystic duct less than 4 mm, more than 3–5 CBD stones, large stones greater than 6–10 mm, or if the cystic duct entrance is not on the lateral (right) aspect of the CBD.11,25 These are not necessarily absolute criteria for failure, but consideration should be given to time under general anesthesia and to surgeon experience (Table 2).

If stones cannot be removed using the TC approach, a laparoscopic TD approach may be performed. The TD approach requires additional skill and technique and confers more risk to patients. A balance must be weighed between dissection and incision of the CBD and the availability of postprocedure ERCP. The patient’s anatomy, including the presence of Roux-en-Y gastric bypass, must also be considered. Some recommend proceeding with the TD approach only if the CBD is dilated to at least 8–10 mm.11,13,25

The steps to a TD-LCBDE are as follows. The cystic duct can be dissected inferiorly to identify the CBD. The CBD is dissected from the fatty tissue in the porta hepatis. A longitudinal incision is made on the anterior aspect of the CBD as low as possible to avoid the vascular supply and to preserve the length of the CBD if reconstruction is ultimately required.13,26 The incision should be approximately 1 cm, or the smallest size necessary to remove the largest stone.2,13 Stay sutures may be placed per surgeon preference. The choledochoscope is then inserted into the CBD, and the operation proceeds similarly to the TC approach.

The incision on the CBD may be closed either primarily with 3-0 polydioxanone or similar suture, or closed over a T-tube.2,26 A systematic review has shown that primary closure does not increase bile leaks or serious complication rates, and T-tube closure may increase operative time and hospital stay for patients undergoing LCBDE.27 Many surgeons have moved toward closing the ductotomy primarily,13,25,26 as long as there is no pancreatitis, cholangitis, substantial inflammation, residual CBD stones, and the CBD is not extremely dilated.13 Other options have been to close over an antegrade stent; however, this has been associated with an increased rate of postoperative pancreatitis.26 A Jackson-Pratt or Blake drain is placed near the CBD at the completion of the procedure.

Potential Postoperative Complications

The TC approach is generally preferred by surgeons as it has a shorter procedure time,28 avoids drain placement,25 and avoids the difficult technical aspect of closing the ductotomy laparoscopically.2 It has a similar recovery to LC, and patients are often discharged the same day or the day after surgery.29 There are no differences in technical success rates or rates of conversion to an open procedure comparing TC and TD approaches. There are fewer perioperative complications, fewer biliary complications, and a shorter hospital stay with the TC approach.28 The risk of bile leak after the TC approach is approximately 1–2% in recent studies.26,28,29

Other postoperative complications include retained stones (stones not cleared with the original procedure) or recurrent stones (stones that later develop within the biliary tree).29,30 In a Cochrane database systematic review published in 2013, 8% of LCBDE patients had retained stones, while 14% in the two-stage ERCP + LC group had retained stones, although this was not a statistically significant difference19. More recent retrospective reviews have reported retained stone rates at approximately 2%.29,30

In studies that review complications of junior surgeons performing LCBDE, there have been no significant differences in morbidity compared to more experienced surgeons. In a comparison of “nonexpert” surgeons who had performed <10 cases of LCBDE to “expert” surgeons who had performed >10 cases, there was a difference in operative time; however, there was no difference in perioperative morbidity, mortality, or hospital stay.31 In an additional study comparing “specialists” and “nonspecialists,” specialists were found to have higher rates of success, but this difference was 90.8% compared to 82.6%. As there were no differences in perioperative morbidity, the authors concluded that 82.6% was an acceptable success rate for nonspecialists.32 Indeed, even experienced surgical trainees have similar outcomes with LCBDE when compared with consulting surgeons.33

Developing a Program

As with any adoption of a new surgical technique, both a system and an individual approach must be taken to ensure success. It takes time for the surgeon to develop the skill of laparoscopic TC-LCBD exploration, which is generally considered difficult. A proficient assistant is needed while choledochectomy is being performed, which could be a limitation for some surgeons. Certainly, the modern surgeon faces pressure to quickly complete surgical procedures. Those that have studied learning curves in LCBDE have found that institutional learning curves may be approximately 200–250 cases,26,29 and individual learning curves may be approximately 60 cases for complete competency.34 As learning improved, one group improved their rate of TC exploration from 5 to 80% from their first 100 cases to their last 300-400 cases.26 As surgeon skill improves, operative time for the procedure also decreases.29,31,34

Surgical training modules have been an important part of increasing surgeon confidence with new procedures, and there are training modules available for surgeons to practice LCBDE. We prefer using the Boston Scientific model for both attending and surgical resident training (Boston Scientific, Marlborough, Massachusetts, United States of America). Alternatively, a porcine aorto-renal model has been described and is an additional option. The renal arteries simulate the cystic duct and hepatic ducts, and the aorta simulates the CBD. The porcine aorto-renal model had high validity and was found to increase operator confidence scores.35

The goal of an institutional program is to provide consistent care to similar patients across the hospital system and to limit surgeon-to-surgeon variation. The direct to surgery approach benefits not only the patient but also the system by increasing patient throughput and by improving the finances of the surgical division. Surgeon compensation is also adequate, as LC + LCBDE is worth 18 relative value units (RVUs) compared to 11.47 RVUs for LC with IOC.36

Implementation of our LCBDE program involved both institutional and departmental support. Both surgeons and residents underwent a model training program. All initial cases were double-scrubbed by two attending along with a resident to increase exposure to the procedure and assist with troubleshooting. The Boston Scientific surgical representatives were available at all possible LCBDE cases and aided with setup and troubleshooting. Collaboration with the emergency medicine department was necessary to encourage an early surgical consult, as the prior institutional culture was to admit patients with gallstone pancreatitis to the medicine service. This is consistent with prior research showing that patients with surgical diseases admitted to surgical services may have better outcomes in terms of time to surgery, hospital stay, cost,37 and patient satisfaction.38

CONCLUSION

The evidence supports a direct to surgery approach for patients with suspected choledocholithiasis. Adopting the technique of LCBDE may seem daunting or even worthless to the surgeon who has available skilled endoscopy. However, the safety and efficacy of LCBDE is similar, if not better than LC + ERCP,19 and it is strongly encouraged by those who perform it.11,28 LCBDE, especially the TC approach, offers the patient a minimally invasive procedure to manage choledocholithiasis, prevents risks associated with an additional anesthetic, and decreases the length of hospital stay,18,19,28 which is beneficial to both the patient and hospital resources.

Overall, training in laparoscopic CBD exploration is a skill that has been somewhat lost for surgeons in the past few decades as the management of choledocholithiasis has largely been via the two-stage approach of LC + ERCP. Unfortunately, surgical residents are not often trained in this procedure in the modern era and therefore may feel unequipped to surgically manage choledocholithiasis in their practice. Despite being considered an advanced procedure, general surgeons and surgical trainees have similar outcomes and acceptable success rates with LCBDE and should be encouraged to learn and perform this procedure if interested. Adding this technique to the surgeon’s repertoire provides the opportunity to improve patient care and increase surgical expertise. It will benefit both surgeons and patients to shift the trend back toward surgically focused care of gallstone disease.

ORCID

Elise A Biesboer https://orcid.org/0000-0002-7639-1955

Patrick B Murphy https://orcid.org/0000-0002-6086-8966

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