A balanced approach to choledocholithiasis

Background: We set out to review and evaluate the results of an algorithm f or managing choledocholithiasis in patients undergoing laparoscopic cholecy stectomy. Methods: We performed retrospective review of patients with choledocholithi asis at the time of laparoscopic cholecystectomy (LC) between March 1993 an d August 1999 All patients were operated on under the direction of one surg eon (M.E.A), following a consistent algorithm that relies primarily on lapa roscopic transcystic common bile duct exploration (TCCBDE) but uses laparos copic choledochotomy (LCD) when the duct and stones are large or if the duc tal anatomy is suboptimal for TCCBDE. Intraoperative endoscopic retrograde sphincterotomy (ERS) is done if sphincterotomy is required to facilitate co mmon bile duct exploration (CBDE). Postoperative endoscopic retrograde chol angiopancreatography (ERCP) is utilized when this fails. Preoperative ERCP is used only for high-risk patients. Results: A total of 728 LC were performed, and there were 60 instances (8.2 %) of choledocholithiasis. Primary procedures consisted of 47 TCCBDE; 37 of them required no other treatment. In five cases, the stones were flushed w ith no exploration. Intraoperative ERS was performed three times as the onl y form of duct exploration. LCD was utilized twice; one case also required intraoperative ERS, and the other had a postoperative ERCP for stent remova l. One patient with small stones was observed, with no sequelae. Preoperati ve ERCP was done twice as the primary procedure. Of the 10 cases that were not completely cleared by TCCBDE, three had a postoperative ERCP and seven had an intraoperative ERS, one of which required a postoperative ERCP. Ther e were three complications (6%) related to CEDE, with no long-term sequelae . There were four postoperative complications (6.7%) and no deaths. The mea n number of procedures per patient was 1.12. The average postoperative hosp ital stay was 1.8 days (range, 0-14). Conclusions: Choledocholithiasis can be managed safely by laparoscopic tech niques, augmenting with ERCP as necessary. This protocol minimizes the numb er of procedures and decreases the hospital stay.