Laparoscopic transcystic management of choledocholithiasis

Our objective was to review our community hospital experience with laparosc opic management of choledocholithiasis from 1991 to 1997. We performed a re trospective review of all case records of patients with choledocholithiasis managed surgically at St. Francis Hospital during the study period. Data r egarding the history, presentation, investigations, operative details, and follow-up were recorded. Procedures were performed by multiple attending su rgeons supervising surgical residents. All common bile duct explorations (C BDEs) were performed by a transcystic approach and followed routine cholang iography. In most cases, cystic duct dilatation over a guide wire was follo wed by transcystic CEDE with choledochoscopy. Stone extraction was accompli shed through a combination of flushing, basket manipulation, fragmentation, retrieval, or advancement of stones through the ampulla. Data were analyze d using SPSS computer software, and P < 0.05 was considered statistically s ignificant. During the period of study there were 1053 laparoscopic cholecy stectomies with and without cholangiography and 100 total CEDE performed. O f these, 54/100 had an attempt at laparoscopic CEDE. There were 39 females and 15 males, with a median age of 52 years (range 14-88). Presentation inc luded acute cholecystitis or biliary colic (63%), gallstone pancreatitis (2 0%), and jaundice or cholangitis (17%). Successful laparoscopic stone remov al was achieved in 36 of 54 (67%) cases. Eighteen of the remainder (33%) we re converted to an open procedure. Size, number, position of stones, techni cal difficulties in accessing the common bile duct, and patient factors con tributed to open conversion. The rate of successful laparoscopic CEDE impro ved for each individual surgeon from an average of 22 per cent in the first half of the study period (1991-1994) to 87 per cent in the second half (19 95-1997). There was no operative mortality. Significant morbidity in the la paroscopic group included one retained stone and two cases of postoperative pancreatitis. There were three false negative preoperative endoscopic retr ograde cholangiopancreatography examinations. Multivariate analysis showed that experience of the individual surgeon was the only significant factor p redicting successful laparoscopic CEDE. Low initial success rate in the ear ly phase of the study period improved dramatically to reach an overall succ ess rate of 87 per cent in the second half. Laparoscopic management of comm on bile duct stones is possible in a community setting with a high success rate and minimal morbidity. It precludes excessive use of endoscopic retrog rade cholangiopancreatography with its own set of complications but is asso ciated with a significant learning curve. It is currently our preferred the rapeutic approach for choledocholithiasis discovered pre- or intraoperative ly.