Choledochoscopy With Laparoscopic Cholecystectomy

Patients with bile duct pathology can be a diagnostic and therapeutic challenge. If choledocholithiasis is suspected during laparoscopic cholecystectomy and cholangiography, a common bile duct exploration is performed. Diagnosing bile duct stones before surgery can be difficult, although the incidence of these calculi ranges from 10% to 12% of all patients undergoing cholecystectomy. Preoperative ultrasonography will predict these stones only 24% of the time and serum liver function tests may only predict bile duct stones 30% to 35% of the time.
Compared with radiologic imaging, the use of the flexible endoscope for direct visualization of the gastrointestinal tract does provide the sur-geon with greater diagnostic and therapeutic ad-vantages in the management of gastrointestinal diseases. The application of this technology to biliary tract disease with the holedochoscope has allowed physicians to more easily diagnose biliary tumors, strictures, and calculi, and it can be ef-fective in removing bile duct stones. Instrument maneuverability depends on the flexibility of the distal tip of the instrument and varies from one instrument to another. Tip deflection greater than 100° in the up/down and left/right movements increases the endoscope flexibility and hence its ability to ac-complish the therapeutic task.
The choledochoscope can be introduced into the bile duct in several ways. The most common method is during the time of laparoscopic or Open bile duct exploration in which the endoscope is indirectly inserted into the bile duct via the cystic duct or directly into the bile duct through a cho-ledochotomy. The proximal and distal bile ducts can be visualized and the choledochoscope can be passed through the papilla into the duodenum if necessary.
The primary indications for intraoperative choledochoscopy include a filling defect on the operative cholangiogram that may be a bile duct stone, stricture, tumor, or a polypoid lesion in the bile duct. Another indication for the use of intra-operative choledochoscopy is to evaluate the bile duct after stones have been extracted to be sure that all biliary calculi have been removed.
Several investigators have reported their re-sults from intraoperative choledochoscopy and they found therapeutic choledochoscopy to be successful in 91.1% of the patients (range, 67% to 100%) with a complication rate of 9.9% (range, 0% to 36%). Although the majority of the com plications were minor, the incidence of major complications such as bile leak, bleeding, bile duct perforation, pancreatitis, and common bile duct stricture was not insignificant.
Postoperative choledochoscopy is possible when the patient’s bile duct has been explored intraoperatively and a 12 to 15 F T-tube has been placed. The primary indications for postoperative choledochoscopy are retained bile duct stones, filling defects in the bile duct, or bile duct stric-tures seen on postoperative cholangiography. In this situation, the 12 to 15 F T-tube tract is dilated with a balloon to 15 mm after it has matured for 4 to 6 weeks, and two 0.035&dquo; guide-wires are inserted into the bile duct under fluo-roscopic guidance. One wire is used as a safety wire and the second wire is b’ackloaded into the choledochoscope accessory channel for rapid in-sertion of the endoscope into the bile duct. Con-tinuous bile duct irrigation with saline through the choledochoscope is used as previously de-scribed, and under direct vision, a 4-wire helical basket and/or balloon stone extractor are used for stone removal.