The 27th Annual conference of Iranian Association of Internal Medicine May 3 - 6, 2016 Razi center for conference Halls, Tehran, Iran.
Laparoscopic Common Bile Duct Exploration
(1)Department of Surgery, Erfan Hospital, Tehran, Iran
OBJECTIVES: Common bile duct (CBD) stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy (LC). Clinical models are inaccurate in predicting CBD stones. Prior to the development of LC, the management of these patients included CBD exploration at the time of cholecystectomy. In the era of LC, because of an obvious lack of expertise in laparoscopic surgery, if the diagnosis of choledocholithiasis was established during intraoperative cholangiography (IOC), the surgeon was confronted with the choice between conversion to open surgery, or postoperative ERCP (two-stage treatment). With increasing experience of laparoscopic surgeons, it seemed logical to develop a mini-invasive one-stage Laparoscopic common bile duct exploration (LCBDE). METHODS: This study evaluates our results of LCBDE in a series of 960 patients treated over 106 months. The purpose of this study is to evaluate the feasibility and safety of LCBDE during LC. The inclusion criterion was the presence of ultrasound proven gallstones. Patients were excluded from the study if there was evidence of carcinoma of the gallbladder. RESULTS: CBD stones were demonstrated in 108 patients by routine IOC. For 17 patients, post-operative ERCP was performed. LCBDE was done in 91 patients; all LCBDEs were completed laparoscopically. In 41 patients, CBD closed on a C-Tube and in 29 patients LCBDE completed with T-tube insertion. In 38 cases no CBD drainage was performed. In 98 cases flexible choledochoscopy was done. Choledochoduodenostomy was performed in 45 cases. The mean operative time was 90-130 minutes (mean 85), which is significantly greater than conventional LC (range 20-40 minutes, mean 30). LCBDE was performed without immediate or late major complications. CONCLUSION: There are no debates in the detection and the management of CBD stones in the era of LC. LCBDE is a cost-effective, efficient, and minimally invasive method of treating choledocholithiasis. RECOMMENDATION: We believe that for surgeons familiar with open common bile duct exploration and laparoscopic cholecystectomy, the next logical step is laparoscopic exploration of the common bile duct at the time of cholecystectomy, which is safe and readily mastered. It is hoped that LCBDE will be adapted to laparoscopic surgeons so patients can undergo a single procedure to remove their gallstones and common bile duct stones if they exist and to decrease the incidence of normal preoperative ERCPs, the complications related to ERCP, and the need for a second procedure postoperatively to clear stones if they are found. Nobody can submerge the importance & need for ERCP particularly in retained stones even after LCBDE.
Keywords: Laparoscopic Cholecystectomy, Choledocholithiasis, common bile duct, stone, exploration.
Shahram Nazari, MD. Consultant & Lecturer in Surgery, Department of General and Laparoscopic Surgery, Erfan Hospital, Tehran, Iran. No:36, Afarin St.,Alvand Ave.,Argentin Sq.,Tehran 1516636111,IRAN.
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