All-comers policy for laparoscopic exploration of the common bile duct

Abstract

Background: Laparoscopic exploration of the common bile duct is associated with substantial variation in results suggesting that different patient populations are being reported. This report observes the results in a defined population and on an intention-to-treat basis.

Methods: All patients with suspected bile duct stones who were fit for surgery from April 1994 were offered laparoscopic bile duct exploration. There were 224 patients of mean age 56 years, of whom 174 were women. Endoscopic sphincterotomy was used in 149 patients deemed unfit for surgery. All data were recorded prospectively and checked at the time of discharge. Patients were followed up after 6 months and beyond after the operation.

Results: Stones were removed transcystically in 56 patients, transductally in 158 and by flushing in nine. The duct clearance rate was 96 per cent overall, 98 per cent for transcystic and 94 per cent for transductal exploration. Intracorporeal lithotripsy safely reduced the failure rate of exploration from seven of the first 28 to four of the subsequent 196 procedures. Biliary complications occurred in 16 per cent of procedures in which a T tube was used but only 4 per cent if the duct was closed by suturing. Conversion to open operation for severe gallbladder inflammation was necessary in 6 per cent of patients. There were no deaths, bile duct injuries or pancreatitis but complications occurred in 19 per cent, associated with use of T tubes and advancing age. Laparoscopic duct exploration succeeded in seven patients after previous cholecystectomy.

Conclusion: Laparoscopic bile duct exploration is effective and safe when used for all patients. For young and fit patients it should replace endoscopic sphincterotomy.