The significance of cystic duct stones encountered during laparoscopic cholecystectomy

Background: Cystic duct stones (CDS) are occasionally encountered during la paroscopic cholecystectomy (LC). They may be noticed during the dissection of the cystic pedicle or seen to extrude from the cystic duct (CD) when it is divided or opened to perform the intraoperative cholangiogram (IOC). The procedures for dealing with CDS range from the simple removal of stones th at fall out when the duct is opened to incising the duct over an impacted s tone to facilitate its removal or converting to open surgery due to a large stone in a CD adherent to the bile duct (e.g., Mirizzi syndrome). Therefor e, we set out to establish criteria that might be predictive of CDS, to exa mine the technical problems caused by them, to look for the most effective ways of avoiding adverse consequences, especially the risk of missing bile duct stones. Methods: We performed a review and analysis of a database that included pre operative, operative, and postoperative data for all patients treated at ou r hospital who were found to have CDS. Results: In a series of 520 LC performed over a period of 5 years, 64 cases of CDS were documented (12.3%). The preoperative risk factors in 45 of the se cases (70.3%) were recent sever acute pain with or without liver functio n test (LFT) derangement (34.3%), jaundice (14%), pancreatitis (14%), and p revious acute cholecystitis (7.8%). At operation, a single stone was found in the CD in 64% of the cases; multiple stones were found in 36%. Dissectio n of the pedicle was difficult in 21 cases and had to be carried out fundus -first in four cases. The CD was reported to be wide in 18 cases; five of t hem eventually needed to be closed with endoloops. Operative difficulty was reported in three of 19 cases where there were no preoperative risk factor s. Simple removal of the stones was possible in most cases. CDS needed be c rushed, the CD incised, or the procedure converted to open in only five cas es (7.8%). IOC was attempted in all cases; it was normal in 39 (61%) and fa iled in two cases (3%). Eighteen patients (28%) were found to have bile duc t stones: another five (7.8%) had CBD dilation or debris indicating possibl e recent passage of stones. Fourteen transcystic and nine direct hilt: duct explorations were performed. Conclusion: Some CDS may slip from the gallbladder into the CD or the CBD d uring dissection. Carefill retraction and manipulation should therefore: be done to minimize this risk. Most CDS are easy to deal with, but some of th em can result in increased operative difficulty. if IOC is not carried out on a routine basis, it becomes mandatory if CDS are encountered because les s than or equal to 35% of them may be associated with bile duct stones.