Laparoscopic common bile duct exploration through the cystic duct using flexible cholangioscopy combined with cholecystectomy for managing cholecysto-choledocholithiasis

Common bile duct (CBD) stones are present in approximately 3 % to 16 % patients with symptomatic gallstones [1] [2] [3]. Laparoscopic common bile duct exploration (LCBDE) and laparoscopic cholecystectomy (LC) could treat cholecysto-choledocholithiasis in one session. However, some drawbacks including the unsatisfactory controllability of the surgical choledochoscope, postoperative bile leak, and the use of the T-tube have hindered the further development of LCBDE + LC. To solve these problems, we introduced LCBDE through the cystic duct using a more flexible cholangioscope combined with cholecystectomy for cholecysto-choledocholithiasis.

A 59-year-old man with abdominal pain underwent computed tomography (CT) examination and the result showed cholecysto-choledocholithiasis. He chose LCBDE + LC to treat the gallstones and CBD stones in one session. During this procedure, we used a novel cholangioscope with flexible controllability, which was initially designed as a single-operator peroral cholangioscopy system [4].

First the gallbladder, cystic duct, and cystic artery were dissociated under laparoscopy, and the cystic artery was cut off using the electrocoagulation function. Then a 5-mm incision was created on the cystic duct ([Fig. 1 a]). The cholangioscope was inserted into the cystic duct through the trocar with the help of the laparoscope ([Fig. 1 b]). Multiple CBD stones were found and extracted using a basket under cholangioscopy in multiple sessions ([Fig. 2], [Fig. 3]). No residual stones were found under cholangioscopy and cholangiography ([Fig. 4]). Finally, the cystic duct was clamped, and the gallbladder was removed ([Fig. 5], [Video 1]). The patient’s recovery was smooth without any adverse events.

Fig. 1 Laparoscopic image of common bile duct (CBD) exploration through the cystic duct. a A 5-mm incision was created on the cystic duct. b The cholangioscope was inserted into the cystic duct through the trocar with the help of the laparoscope.

Fig. 2 Cholangioscopy image of common bile duct exploration through the cystic duct. a Multiple CBD stones were found. b CBD stones were extracted using a basket.

Fig. 3 CBD stone was removed from the cystic duct under laparoscopy.

Fig. 4 No residual stones were found under cholangiography.

Fig. 5 The cystic duct was clamped, and the gallbladder was removed.

Video 1 Laparoscopic common bile duct exploration through the cystic duct using flexible cholangioscopy combined with cholecystectomy.

Download Video

Of note, this is the first experience of this technique in our team, and we hope that patients with cholecysto-choledocholithiasis can benefit from this procedure if conditions allow.

The advantages of this technique over traditional LCBDE + LC include better controllability, enabling complete clearance of CBD stones, and a smaller incision in the cystic duct instead of the CBD, avoiding the placement of a T-tube and postoperative bile leak.

Endoscopy_UCTN_Code_TTT_1AR_2AH

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 2016; 65: 146-181
• 2 Tazuma S. Gallstone disease: Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol 2006; 20: 1075-1083
• 3 Collins C, Maguire D, Ireland A. et al. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg 2004; 239: 28-33
• 4 Zhang W, Chai N, Zhai Y. et al. Cholangioscopy-assisted extraction of choledocholithiasis and partial sediment-like gallstones through papillary support: A pilot exploration for super minimally invasive surgery. Endoscopy 2023; 55: E274-E275

Publication History

Article published online:
21 April 2023