COMBINED LAPAROSCOPIC AND ENDOSCOPIC MANAGEMENT OF CHOLELITHIASIS ANDCHOLEDOCHOLITHIASIS

With the advent of laparoscopic cholecystectomy, optimal management of common duct stones remains controversial. Seven hundred six patients underwent laparoscopic cholecystectomy in our institution from January 1990 through January 1992. From this group of patients, 50 were ident ified as having clinical or radiographic evidence of common duet stone s. Thirty-one patients demonstrated preoperative risk factors for comm on duct stones and underwent preoperative endoscopic retrograde cholan giopancreatography (ERCP). The risk factors included jaundice (19%), p ancreatitis; (23%), elevated liver function tests (52%), and ultrasoun d evidence of choledocholithiasis (6%). Preoperative ERCP was performe d in 94% of patients. There were two failures due to periampullary div erticula. Common duct stones were identified in 18 patients (62%) and successfully removed by endoscopic sphincterotomy in all of these pati ents. Nineteen patients were found to have unsuspected common duet sto nes on intraoperative cholangiography. Eighteen patients (95%) underwe nt Successful ERCP and endoscopic sphincterotomy with stone extraction . Overall, major morbidity was 2% and included one patient who experie nced endoscopic sphincterotomy-related bleeding that required surgical sphincteroplasty. The three endoscopic failures were managed by open common duct exploration, laparoscopic duct exploration, and combined l aparoscopic and open common duct exploration. We conclude that combine d laparoscopic and endoscopic therapy is a viable option for the manag ement of cholelithiasis with choledocholithiasis.