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Gallstones and gallbladder disease - Open or Laparoscopic Common Bile Duct Exploration (Choledocholithotomy)

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of gallstones.

Alternative Names

Cholecystitis; Choledocholithiasis; Bile duct stones

Open or Laparoscopic Common Bile Duct Exploration (Choledocholithotomy):

Laparoscopic Exploration and Cholangiography

Surgeons are now increasingly using laparoscopy with cholangiography instead of ERCP when common duct stones are suspected. Laparoscopy with cholangiography should only be done in centers with expertise in this procedure. This procedure should be done for the following reasons:

As an alternative to ERCP before gallbladder surgeries, when there is a high suspicion of common bile duct stones.
During gallbladder surgeries when common duct stones are detected or highly suspected.

The procedure usually involves the following steps:

The initial approach is the same as with laparoscopic cholecystectomy. One or two 10 - 12 mm (around half an inch) incisions and three 5 mm (about a fifth of an inch) incisions are made in the abdomen.
A tiny opening is made in the cystic duct that connects the gallbladder to the bile duct, and a thin tube is introduced to perform a cholangiography.
If stones are identified, the surgeon inserts a tube with an inflatable balloon to widen the duct.
Stones are usually retrieved or withdrawn from the duct with either a balloon or tiny basket.
If laparoscopy is unsuccessful, ERCP or open surgery is performed.

Experts are debating whether this procedure is better than ERCP. Many surgeons believe that laparoscopy is becoming safe and effective, and should be the first choice of treatment. Still, laparoscopy for common duct stones should be performed only by experienced surgeons.

Open Common Bile Duct Exploration (Choledocholithotomy)

Choledocholithotomy, or common bile duct exploration, is used:

To remove large stones
When the duct anatomy is complex
During or after some gallbladder operations when stones are detected. If the procedure is being performed laparoscopically, the surgeon may convert to an open procedure, though this happens less often now.
When ERCP or laparoscopic procedures are not available.

In this procedure, the doctor performs open abdominal surgery and extracts gallstones through an incision in the common bile duct. Routinely, a "T-tube" is temporarily left in the common bile duct after surgery and the doctor x-rays the bile duct through the tube 7 - 10 days after surgery, to determine whether any stones remain in the duct.

Resources

http://digestive.niddk.nih.gov -- National Digestive Diseases Information Clearinghouse
www.gastro.org -- American Gastroenterological Association
www.acg.gi.org -- American College of Gastroenterology
www.liverfoundation.org -- American Liver Foundation

References

Afdhal NH. Diseases of the Gallbladder and Bile Ducts. In: Goldman L, Ausiello D. (eds.). Cecil Textbook of Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007.

Chambrlain RS, Sakpal SV. A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg. 2009 May 2 [Epub ahead of print].

Chari RS, Shah SA. Biliary system. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery. 18th ed. St. Louis, MO: WB Saunders;2007:chap 54.

Dray X, Joy F, Reijasse D, et al. Incidence, risk factors, and complications of cholelithiasis in patients with home parenteral nutrition. J Am Coll Surg. 2007;204(1):13-21.

Gurusamy, KS, Samraj K. Cholecystectomy versus no cholecystectomy in patients with silent gallstones. Cochrane Database Syst Rev. 2007;(1):CD006230.

Ito K, Ito H, Whang EE. Timing of Cholecystectomy for Biliary Pancreatitis: Do the Data Support Current Guidelines? J Gastrointest Surg. 2008 Jul 18 [Epub ahead of print].

Konstantinidis IT, Deshpande V, Genevay M, Berger D, Fernandez-del Castillo C, Tanabe KK, et al. Trends in presentation and survival for gallbladder cancer during a period of more than four decades. Arch Surg. 2009;144(5):441-447.

Liu B, Beral V, Balkwill A, Green J, Sweetland S, Reeves G, et al. Gallbladder disease and use of transdermal versus oral hormone replacement therapy in postmenopausal women. BMJ. 2008;337:a386. Doi: 10.1136/bmj.a386.

Portenier DD, Grant JP, Blackwood HS, et al. Expectant management of the asymptomatic gallbladder at Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007; 3(4):476-479.

Rosing DK, de Virgilio C, Yaghoubian A, et al. Early cholecystectomy for mild to moderate gallstone pancreatitis shortens hospital stay. J Am Coll Surg. 2007;205(6):762-766.

Strasberg SM. Acute calculous cholecystitis. N Engl J Med. 2008;358(26):2804-2811.

Tse F, Liu L, Barkun AN, Armstrong D, Moayyedi P. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc. 2008;67(2):235-244.

Verbesey JE, Birkett DH. Common bile duct exploration for choledocholithiasis. Surg Clin N Am. 2008;88(6):1315-1328.

Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008;57(7):1004-1021.

Reviewed last on: 6/26/2009
Reviewed by: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

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