Laparoscopic Approach in the Case of Biliary Obstruction: Choledocholithiasis

Abstract

Obstruction of the biliary tree may be caused by a number of benign and malignant conditions. The most common cause of biliary tree obstruction is due to stones, a condition known as choledocholithiasis. This is a potentially life-threatening condition, requiring urgent diagnosis and treatment. Endoscopic retrograde cholangiopancreatography (ERCP) is currently the most common intervention carried out in the treatment of obstructive jaundice. Laparoscopic common bile duct exploration, first performed about 30 years ago, has an important place in the management of choledocholithiasis. The laparoscopic approach is considered a safe and effective method for the removal of common bile duct stones, comparable to the results of ERCP.

1. Introduction

The unhindered passage of bile from the liver into the duodenum requires a patent biliary tree and is a prerequisite for efficient hepatic function. Any obstruction of the biliary tree may lead to obstructive jaundice.

Associated adverse consequences of obstructive jaundice, such as coagulopathy, hypovolemia, endotoxemia, and sepsis, can develop rapidly and significantly increase the mortality and morbidity of these patients due to multi-organ failure. Acute obstructive cholangitis (AOC) is a frequent complication of biliary obstruction provoked by stones in the common bile duct (CBD). According to the different authors, the morbidity and mortality in such circumstances are up to about 20-30% [1, 2].

The need for urgent decompression of the CBD is vitally essential for these patients. There are four different approaches to do this, for example, ERCP, laparoscopic approach, percutaneous biliary drainage, or open surgical access.

Today, laparoscopy is the preferred method of surgery for a wide range of pathology ranging from cholecystitis to colon carcinoma; practically every part of the gastrointestinal tract can be operated on by laparoscopy. With the introduction of laparoscopic common bile duct exploration (LCBDE), about 30 years ago, now we could resolve the problem of biliary obstruction with lesser risk for the patient.

2. Obstructive jaundice and treatment modalities

Obstructive jaundice is not an uncommon clinical entity caused by different benign or malignant diseases. The most common benign pathology of the bile ducts worldwide is choledocholithiasis defined as the presence of stones in the common bile duct (CBD). According to the different authors, CBD stones are present in 10–25% of all patients undergoing cholecystectomy for stones in the gallbladder and in about 10% of patients who undergo cholecystectomy for symptomatic cholelithiasis (gallstones in the gallbladder). On the other hand, 95% of patients with confirmed choledocholithiasis have stones in the gallbladder too. CBD stones can remain silent for a long time, but they can also be associated with recurrent upper abdominal pains, intermittent jaundice, cholangitis, and recurrent pancreatitis. According to the recommendations, choledocholithiasis (CCL) should be confirmed in the perioperative period because of its direct relation with the bile leaks in the early postoperative period of cholecystectomy [3, 4, 5, 6].

Chronic pancreatitis can also impede the excretion of bile into the duodenum. The malignant causes may be a biliary tumor, pancreatic cancer, ampulla of Vater, or duodenal tumor.

The iatrogenic cause (e.g., misplaced clip after laparoscopic cholecystectomy) can also be an explanation for extrahepatic bile duct obstruction at the time of the widely accepted laparoscopic surgical approach [7, 8, 9, 10].

In most benign biliary diseases, jaundice is intermittent, not long-lasting, and provoked by incomplete bile duct obstruction. Only a few benign diseases (e.g., primary sclerosing cholangitis) result in persistent obstructive jaundice, in biliary cirrhosis and portal hypertension, and most cases are related to stone obstruction complicated or not with cholangitis [11, 12]. The benign pathology associated with jaundice has usually total bilirubin level less than 100 μmol/l and that condition is well tolerated by the patients. In contrast, the malignant obstructive jaundice is usually a prolonged process with total bilirubin level greater than 100 μmol/l. This devastating disorder is generally observed in older adults with compromised immune system, chronic organ dysfunction or other health problems. The malignant biliary obstruction is rarely associated with acute cholangitis at the time of clinical diagnosis [13].

All patients with obstructive jaundice usually present a different degree of icterus (depending on the level of hyperbilirubinemia), dark urine, pale stools, and itchy skin (pruritus). Right hypochondrial abdominal pain, radiating to the back or right shoulder is very suspicious for acute cholecystitis (Ac) or AOC and is rarely associated with the malignant cause of the biliary obstruction.

AOC is an acute inflammation of the bile ducts caused by bacterial infection. The most common organisms implicated are coliform organisms. These include Escherichia coli (25%-50%), Klebsiella species (10%-20%) and Enterobacter species (5%-10%).

The diagnosis of obstructive jaundice is based on the clinical signs, laboratory data, and imaging findings.

AOC is first described by Charcot in 1877. Charcot’s triad (fever, right upper quadrant pain, and jaundice) actually occurs in only up to 75% of patients with acute cholangitis (biliary infection) and carries a poor sensitivity [21.2–26.4%]. Association of these clinical signs with altered mental status (confusion) and signs of shock (hypotension and tachycardia) known as Reynolds pentad is suggestive of suppurative cholangitis, which is reported in up to 7.7% of all jaundiced patients [14]. The diagnosis of acute cholangitis is essential because this complication of biliary obstruction can rapidly progress to a severe form accompanied by organ dysfunction, caused by systemic inflammatory response syndrome (SIRS) and/or sepsis. Prompt diagnosis and thorough assessment of the patient are necessary for appropriate management, including intensive care with organ support, and urgent biliary drainage in addition to early medical treatment.

Usually, biliary infection alone does not cause clinical cholangitis unless biliary obstruction raises the intraductal pressure in the bile duct to levels high enough to cause cholangiovenous or cholangiolymphatic reflux. This can lead to the destruction of the barrier between the capillary bile duct and the liver sinusoid, resulting in sepsis, septic shock, and multiple organ dysfunction due to bacteria entering the bloodstream [15]. Thus, acute cholangitis progresses from local biliary infection to the systemic inflammatory response syndrome (SIRS), and the advanced stage leads to sepsis with or without organ dysfunction. If the obstruction cannot be removed in time, it often rapidly develops into AOC, which is life-threatening. Therefore, early diagnosis, infection control, and removal of bile duct obstruction are primordial for the primary treatment of this complication. Many less-severe biliary tract infections respond to medical therapy alone. However, early recognition of patients with severe infection and sepsis requiring immediate procedural intervention is crucial, as delayed biliary decompression after failure of medical therapy carries a mortality rate up to 80% [16].

According to the literature in the 1970s, the mortality rate of patients with acute cholangitis was reported to be over 50%, but with advances in intensive care, new antibiotics, and biliary drainage dramatically reduced the mortality rate to less than 7% by the 1980s. However, in the 1990s, the different authors reported mortality rates in severe cases ranged from 11 to 27%, and even now the severe form of acute cholangitis remains a fatal disease (30% mortality) unless appropriate management is instituted promptly [15, 17, 18, 19].

The algorithm for the diagnosis and treatment of AOC has been debated for many years. The experts reached at the International Consensus Meeting held in Tokyo 2006 define the new criteria for the diagnosis and differentiation between AOC and Ac, known as the Tokyo guidelines. These criteria are based on the history of biliary disease, the clinical manifestations, laboratory data that indicate the presence of inflammation and cholestasis (WBC, CRP, bilirubin, AST, ALT, ALP, and GGT), and imaging findings that indicate biliary obstruction and duct dilation confirmed by MRCP (magnetic resonance cholangiopancreatography), US, CT, and ERCP. Later, the Tokyo Guidelines 2018 defined empiric therapy for acute cholangitis and cholecystitis [20, 21]. According to the Tokyo Consensus Meeting, the severity of acute cholangitis should be divided into three grades—mild (grade I), moderate (grade II), and severe (grade III) based on the response to initial medical treatment and the existence of organ dysfunction. These guidelines try to delineate more precise diagnostic and treatment algorithms for patients with complicated obstructive jaundice [21].

Obstructive jaundice has devastating consequences on every body system, which carries an increased risk to the patient before the intervention and risk of postoperative complications. Even though the early diagnosis requires prompt medical treatment and surgical drainage of the CBD, there is also a risk to increase procedure-related complications.

The need for urgent decompression of the bile duct is essential, especially if the patient has an AOC. There are different procedures for decompression of CBD, for example, ERCP, laparoscopic approach, open surgical access, or percutaneous biliary drainage. Each of these techniques has its benefits and risks, and while making a decision, we should balance the advantages and disadvantages of any of these [7]. But the key question is not only which method for decompression of CBD is better. In each case, we have a specific clinical situation, the technical proficiency of the operator, a particular patient’s general condition, and costs. All these factors should be considered in choosing the most appropriate technique and the one that will achieve the best outcome with less risk.

2.1 Endoscopic retrograde cholangiopancreatography (ERCP)

Regarded as the most common intervention today performed for the treatment of obstructive jaundice, this technique was introduced in 1968 into the clinical practice for visualization of bile ducts. The first cannulation of the papilla of Vater and duct visualization, by contrast, was performed by Dr. William S. McCune, an obstetrician. Several years after that Dr. Meinhard Classen in Germany and Keiichi Kawai in Japan simultaneously undertook the first biliary sphincterotomy and ERCP was developed as a therapeutic option for biliary obstruction.

From then on ERCP has become the first-line modality for the diagnosis and treatment of pancreatobiliary diseases (mainly biliary obstruction and bile duct stones). Today ERCP can be performed before, during, or after cholecystectomy, and may also be combined with either sphincterotomy (transection) or sphincteroplasty (papillary dilatation) for stone retrieval from the CBD or stent placement.

The indication for ERCP is a distal CBD obstruction with CBD dilation, confirmed by MRCP.

The procedure is usually performed under conscious sedation. Biliary decompression by ERCP, even essential in the management of obstructive jaundice, may provoke also acute obstructive cholangitis (AOC), one of the procedure-related complications related to the ERCP [22].

The incidence of post-ERCP cholangitis ranges from 0.4 to 10%, carrying a mortality rate of 0.1%, [23, 24, 25]. If there is a failure of ERCP for biliary stone removal the risk for postoperative AOC is multiplied. However, endoscopic sphincterotomy for bile duct stones has a disappointing 8–10% rate of long-term biliary complications, including recurrent or residual ductal stones, cholangitis, stenosis of the papilla, and biliary pancreatitis [26]. Goodall and Macadam [27] referred to a 28% rate of late symptoms related to low-grade cholangitis following papillosphincterotomy.

Although ERCP has increasingly become a very popular procedure, post-ERCP complication rates may reach 9.7%, with a mortality rate of 0.7%. The four most common complications are [23, 28, 29, 30]:

1. Post-ERCP pancreatitis.

2. Biliary or duodenal perforation.

3. Gastrointestinal bleeding.

4. Acute cholangitis, cholecystitis, liver abscess.

2.2 Percutaneous transhepatic biliary drainage (PTBD)

This procedure is one of the possibilities for the fast resolution of obstructive jaundice in experienced hands. It can be performed by a radiologist using local anesthesia. Started as a percutaneous cholangiography, the first PTBD was reported by Kaplan, who put it in place in 1961. Later the two-step puncture method of PTBD was introduced in clinical practice by Takada et al.

The indication for PTB is intrahepatic bile duct dilation, confirmed by the US.

PTBD was performed under ultrasound (US) and fluoroscopy guidance with localization of the biliary tree and selection of the entry site. The access site can be through the right or left lobe of the liver. Generally, a 21-gauge needle was first introduced under the US guidance into the chosen bile duct. Through the needle, a 0.018″ guidewire is put in place and the needle is exchanged for a 5-Fr catheter for cholangiography. After performing cholangiography and verification of bile duct anatomy, the catheter is then withdrawn and 8-Fr multisidehole catheter is advanced and positioned over the guidewire (Boston Scientific, Boston, USA). The catheter was then secured to the skin and connected to a bag for 48 h. If the tip of the biliary catheter is positioned in the duodenum, the biliary drainage is named internal. If the catheter’s tip is above the biliary obstruction, the drainage is external [31].

The complications of PTBD are as follows:

1. Hemorrhage

2. Pleural effusions

3. Biloma

4. Biliary cholangitis/sepsis

2.3 Laparoscopic common bile duct exploration

After the first open cholecystectomy performed by Langenbuch in 1882, the first successful open CBD exploration (OCBDE) was employed by Courvoisier, in 1890. A century later, in 1985, the first laparoscopic cholecystectomy (LC) was introduced into clinical practice and soon became the standard of care [32]. The first reports about LCBDE are in the early 1990s, when Traverso, who had made some early LCBDE studies, recommended one-step LCBDE to treat CBD stones [3, 33, 34]. According to Traverso and other authors, it is accepted that ERCP may lead to disruption of the sphincter of Oddi and induce several severe postoperative complications, such as pancreatitis, bleeding, and perforation. That is why they seek alternative resolutions to this problem [4, 5, 6, 35].

From then on LCBDE has been employed effectively in thousands of cases, although a relatively small percentage of the biliary tract surgeons practicing this technique today. The reasons for the reluctance to perform LCBDE are numerous (e.g., technical difficulties, prolonged operative time, need for general anesthesia, and need more advanced laparoscopic skills). Although the routine adoption of LCBDE associated with cholecystectomy as a one-stage procedure has been promoted by the constant improvement in techniques and expertise of surgeons who are increasingly confident with laparoscopic hepato-biliary surgery.

It is important to take into account, however, that prior to the introduction of LC, surgeons were apt to clear the CBD system in 90% of cases where they attempted CBD exploration [36, 37]. Since the advent of LC, most surgeons have revoked the opening and cleaning of CBD and returning the biliary tract to its normal healthy status without leaving residual ductal calculi. Instead, they have relied more on alternative and additional interventional methods (e.g., ERCP) to handle these problems [38]. Although this endoscopic technique is certainly useful in managing complicated biliary tract problems, it is not without cost, morbidity, mortality, and significant lifestyle disruption. Even in the best hands, ERCP carried with it morbidity rates as high as 15% and mortality rates of 1%.

At present, the minimally invasive treatment techniques for CBD stones are LCBDE plus laparoscopic cholecystectomy (LCBDE+LC) as the one-stage procedure or endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (ERCP+LC) as a two-stage procedure [39, 40]. The preferred succession is preoperative ERCP+LC (pre-ERCP+LC), which is recommended by the European Association for the study of the liver [41], however, no clear statements have been published regarding the best treatment for CCL. We should take into account that ERCP may cause destruction of the sphincter of Oddi, resulting in reflux of duodenal juice, leading to recurrence of CBD stones, episodes of cholangitis, and even carcinoma. In addition to the ERCP’s complications, such as pancreatitis, bleeding, and perforation, the drawbacks of ERCP are also two-stage procedure, and the patients need to have two different anesthesiologic sessions.

As a one-stage procedure, the important advantages of LCBDE+LC are preserving the function of the sphincter of Oddi with a reduction of the overall hospital stay and cost [39, 42].

The optimal strategies for the management of CBD stones remain controversial and further studies on this topic are recommended according to the literature.

Considering a meta-analysis published in 2018 comparing the outcomes of LCBDE with the pre-ERCP+LC, the authors reported that the pre-ERCP+LC group had a higher CBD stone clearance rate than the LCBDE+LC group (OR 1.63; 95% CI 1.16–2.28; p = 0.005). The study revealed that the pre-ERCP+LC had a lower postoperative bile leakage rate than the LCBDE+LC group (OR 4.08; 95% CI 2.08–7.98; p < 0.0001) and the overall morbidity and mortality was not significantly different between the two groups. Although the overall hospital stay was significantly shorter in the LCBDE+LC group (mean difference [MD], − 2.46 days; 95% CI − 3.67 to −1.24; p < 0.0001), the rate of postoperative pancreatitis was significantly higher in the pre-ERCP+LC than LCBDE+LC group (OR 0.18; 95% CI 0.06–0.50; p = 0.001) [43].

Three prospective randomized studies were published related to the recurrence and residual stones, comparing two techniques LCBDE with ERCP. The authors reported a lower recurrence rate of the LCBDE+LC approach [44, 45, 46].

According to the literature, LCBDE is a safe, effective, and feasible technique that can be applied in the treatment of cholelithiasis even to patients with nondilated CBD (e.g., less than 10 mm in diameter). Although, considering that there are certain difficulties with the operative technique (e.g., cystic duct cannulation or stone extraction) some authors still recommended the application of LCBDE into the clinical practice. In this study including 47 patients with nondilated CBD, the clearance rate of bile duct stones after LCBDE was 100%, with no complications and no mortality occurred [47].

LCBDE has been used worldwide for nearly 30 years, and its advantages are valued by surgeons for a long time. On the other hand, many fragile elderly patients with AOC frequently present systemic concomitant diseases needing emergency admission, diagnosis, and operation. The operation for AOC in the elderly should be simple, quick, and effective because the basic health status of elderly patients is usually fragile. Trying to find a place for LCBDE in the treatment of complicated AOC for elderly patients, there was a study published in 2019 [48]. Enrolling 98 patients (>65 years), divided into three groups (ASA II, III, and IV) according to their general status, the authors found out that LCBDE was a safe, effective, and feasible emergency procedure for treating complicated AC in elderly patients. They noted that all the patients recovered successfully with no mortality, and no residual biliary stones detected by cholangiography before discharge from the hospital. Only three patients had a biliary leak postoperatively that gradually decreased and four patients had a recurrence of CBD stones one year later.

LCBDE can be accomplished with a variety of techniques. There are two basic techniques that give access to the CBD, transcystic approach (via the cystic duct) and transductal approach (via choledochotomy). The benefits of the transcystic method are confirmed and related to minimal morbidity, no T-tube left in the CBD, and a rapid return to normal activity in most cases. The transductal approach is more complicated, but useful in cases where extrahepatic large stones or intrahepatic stones are expected. This approach can be utilized if the cystic duct is too small in size or a very long course precluding its use. The latter approach, however, requires the acquisition of laparoscopic suturing and knot-tying skills not necessary in the transcystic technique [49, 50].

In the case of primary hepatolithiasis, which is a prevailing biliary disorder in eastern and southeastern Asian populations, some authors proposed stone extraction or using cholangioscopy through the left hepatic duct orifice. The reason for that is the left intrahepatic stones account for the majority of cases [51].

According to the medical literature, endoscopic and open surgical interventions of CBD are widely implemented as the standard practice in common bile duct exploration. However, the laparoscopic approach has been also reported to have comparative, even superior outcomes in this concept. This has created an ongoing debate about the ideal approach to adopt in practice.

In 2021, a systematic review of evidence was published on the outcomes of laparoscopic exploration of the common bile duct through transductal and transcystic approaches over the last 10 years. Including 36 relevant papers, 3 meta-analyses, 8 randomized controlled trials, 18 retrospective, 4 prospective studies, and 3 review articles, the authors concluded that LCBDE compared to OCBDE, had significantly lower mortality (0.25% vs. 5.5%), less surgical site infection (1.2% vs. 10%), and overall morbidity (3.7% vs. 22%). The vast majority of the reviewed studies reported that LCBDE (through transductal and transcystic approach) was associated with CBD clearance rates greater than 84% [52].

Comparing the transcystic to the transductal approaches in LCBDE, most studies were in favor of the transcystic route. This can be explained by the lower incidence of associated bile leak (1.4% vs. 6.9%), and shorter duration of hospital stay (4.9 vs. 7.3 days). In addition, one meta-analysis revealed that the mean duration of the operative time was statistically in favor of the transcystic approach (113.8 vs. 126.3 minutes) [52].

The overall conclusion from this systematic review indicates that LCBDE, through transductal or transcystic routes, is safe when performed by an experienced surgeon and on clinically fit selected patients. In addition, there is statistically less overall morbidity and a shorter duration of hospital stay after LCBDE when compared to OCBDE. The conclusion of this review disclosed more successful clinical results of LCBDE in CBD clearance when compared with OCBDE and ERCP [52].

The presumption that LCBDE may have long-term cost-effective benefits may be explained by the fact that LCBDE is performed as single-stage procedure during laparoscopic cholecystectomy, has a shorter length of hospital stay, and decreased utilization of other resources like endoscopy and radiology. On the other hand, the bile leak rates seem to be comparable between LCBDE and OCBDE, and the associated mortality with LCBDE is comparable to the reports associated with OCBDE and ERCP. Also, according to this study laparoscopic transcystic route seems to have a superior outcome when compared to the laparoscopic transductal route regarding bile leak rates [52].

In 2013, the results from 16 randomized clinical trials were published including 1758 participants and comparing the results from OCBDE versus LCBDE versus ERCP for CBD stones. The analysis suggests OCBDE appears to be as safe as ERCP and may even be more successful than the endoscopic technique in clearing the duct stones. LCBDE appears to be as safe as and as effective as the endoscopic technique [53].

According to the opinion of many authors, the overall conclusion was that each of these techniques has its risks and benefits, more reliable studies are needed and the choice depends on the patient’s condition and the surgeon’s expertise and confidence.

3. Perioperative and diagnostic work-up of jaundiced patient

After hospital admission, the patient should undergo routine preoperative laboratory investigations, including total blood count, liver function tests, creatinine, electrolytes, and coagulation tests, such as prothrombin time, partial thromboplastin time, and INR. Routine chest X-rays needed to exclude pleural effusions and cardiac abnormality and ECG are mandatory for those patients with or without clinical signs of cholangitis and septic complications.

If there is any suspicion of sepsis, venous lactate should be requested as well as an ABG in the case of respiratory insufficiency. In most cases, different noninvasive imaging modalities can help the diagnosis of biliary obstruction and CBD dilation, for example, MRCP, US, and CT. ABCD approach should be applied to every patient to exclude or support the life-threatening condition.

When we consider the approach to the patient with obstructive jaundice and the need for intervention, we should take into account the next three factors: existence of life-threatening biliary infection, benign or malignant origin of obstruction, and need for subsequent definitive surgical procedures.

When the patient has an AOC, age > 65 years + comorbidities and his general condition is unstable and does not improve with medical therapy [30% of all patients with AOC] or already is associated with septic shock, there is a need for emergent decompression of the CBD. In this case, [e.g., grade III AOC] a PBD under local anesthesia may be a life-saving, low-risk procedure, allowing correction of fluid, electrolytes, and coagulopathies. In this case, the PBD is a kind of “bridge therapy” before a radical surgical intervention [54, 55].

If the obstruction is benign, age ≤ 65 years, without signs of AOC or septic complications [e.g., grade I or II AOC], we can try definitive surgical procedures to resolve the problem [LCBDE or ERCP].

If the obstruction is malignant, a radical operation is possible and the patient is fit for intervention, an operation could be performed if preoperative TB (total bilirubin) < 162 μmol/L according to the literature. If preoperative TB > 162 μmol/L we can postpone definitive surgical procedures because of the risk of postoperative complications. In this case, we could use a “bridge therapy” (e. g., ERCP, PBD, and LCBDE) to stabilize the patient’s general condition [56].

If the radical operation for malignant obstruction is not possible, we can accomplish ERCP, LCBDE, or PBD, according to the general condition of the patient and life expectancy.

Surgical procedures in patients with obstructive jaundice are associated with a higher incidence of complications than those in non-jaundiced patients. The risk of infectious complications, sepsis, and septic shock is important and preventive measures should be started before any procedure.

Patients with jaundice often fasted for prolonged periods, have depleted extracellular fluid volume, and impaired ability to concentrate urine. They are usually hypovolemic with low albumin and total protein blood level. This hypovolemia with the toxic effect of bilirubin on the renal tubules may provoke a renal insufficiency.

The derangement of coagulation status also should be compensated early by the administration of vitamin K and fresh frozen plasma to restore normal prothrombin time and homeostases.

In summary, according to the literature, we can follow the following recommendations [57]:

1. Restoration of normal fluid volume

We can start the fluid administration in small increments and to keep rigorous control of fluid balance with hourly monitoring of urinary output, blood pressure, and pulse. Our goals are to avoid edema of the body’s extremities and to keep stable blood pressure, pulse, and urine output.

1. Antibiotic prophylaxis should be given to all patients, including those undergoing percutaneous, laparoscopic, and endoscopic procedures.

2. Preoperative assessment of coagulation status, risk of hemorrhage, and administration of vitamin K and fresh frozen plasma, if necessary.

3. Nutritional status should be assessed and supported, including parenteral nutrition for the preoperative period.

4. Multidisciplinary approach for discussion of therapeutic strategy in each individual case. By this approach, with the early involvement of the surgeon, radiologist, and endoscopist, we can choose the most appropriate technique for each patient.

4. Consideration regarding extrahepatic bile duct anatomy of CBDE

The cystic duct is a connection between the gallbladder and the common bile duct. Generally speaking, its length is about 3 cm and its diameter is 0.2–0.3 cm. It consists of two parts, which include 5–12 consecutive half-moon mucosal folds called the Heister spiral valves and a smooth portion close to the CBD. Its elasticity and the smoothness of its interior are similar to the CBD. The muscles of the spiral folds are arranged like an annular valve, which can drive the bile flow by contraction and relaxation. Furthermore, the cystic duct itself functions like a sphincter and can coordinate gallbladder filling. The complex anatomy of this structure could be the explanation of difficulties during extraction of CBD stones through the cystic approach.

The diameter of the confluence between the cystic and hepatic ducts is wider than the diameter of the CBD. That is why we can use it to do a microincision on this part of the bile duct and to provide access to CBD. The diameter of the cystic duct can expand up to 1 cm or more when the CBD is obstructed, and the expansion is more obvious at the confluence. The anatomical features of the cystic duct and CBD create actually favorable conditions for LTCBDE if there are no anatomical abnormalities or variations [58].

5. Ports placement and patient’s installation on the table

Patient preparation for LCBDE is the same as the patient positioning for laparoscopic cholecystectomy [59].

The video monitor is placed on the right side of the patient.

The patient is in a supine position on the operative table with abducted legs strapped to the table. The surgeon stands between the patient’s legs and the first assistant stands on the surgeon’s left side, holding a 30° oblique optic. The second assistant stands on the right side of the surgeon (French position).

After general anesthesia, pneumoperitoneum is created through the umbilicus with a Veress needle usually by closed access technique. Open access is useful if there are adhesions from previous surgery. During the intervention, we maintain the intra-abdominal pressure at 12–13 mmHg. After the creation of pneumoperitoneum, the patient is placed at a semi-Fowler’s 15° position and left lateral rotation of the operating table.

We used the 5-hole method for the operation: the laparoscopic observation hole was located through the umbilicus. There are two working ports for the surgeon, a 10-mm trocar placed under the xiphoid process, and a 5-mm trocar was placed 5 cm below the costal margin at the midclavicular line on the right side. Two additional trocars are placed at the right anterior axillary line and the second one just below the xiphoid. The last port is used for the introduction of a bronchoscope for visualization of distal CBD or Dormia basket, balloon catheter, and blunt forceps for stones extraction from CBD.

6. Application of intraoperative techniques for LCBDE

The laparoscopic CBD exploration should be performed by an experienced surgeon. After exposure to the inferior surface of the liver, we start the dissection in the Calot’s triangle with the identification of cystic duct and cystic artery. After the division of the cystic artery between two 5 mm titanium clips, we assess the diameter of the cystic duct. If it is dilated and thickened, we perform a transverse or T-type microincision at the level of confluence with scissors and the duct is cannulated with a 4- or 5-Fr cholangiogram catheter. By intraoperative C-arm fluorocholangiography, we can visualize the bile duct anatomy and the presence of CBD stones.

The gallbladder is usually left in place, held by the second assistant during laparoscopic exploration of CBD.

From a technical point of view, it is possible to perform the LCBD exploration by a transcystic route or after choledochotomy. Generally, an indication for choledochotomy is a diameter of CBD ≥ 10 mm and a cystic duct ≥5 mm for insertion of 5 mm choledochoscope (Figure 1). Even though the two trials [60, 61] defined minimum required CBD diameters of 6 mm and 7 mm, respectively (as measured by operative cholangiogram) for proceeding with choledochotomy.

Figure 1.

Dilated CBD >10 mm.

The cystic approach is possible even for the diameter of cystic duct of 3 mm. In this case, we try in advance to dilate the cystic duct by the balloon catheter and apply a 3 mm choledochoscope through it (3 mm choledochoscope, Karl Storz).

Before longitudinal incision on the CBD (Figure 2) we place two stay sutures (at 3 o’clock and 9 o’clock) (Figure 3). This can help visualization and improve one’s ability to properly direct the incision. When the diameter of the cystic duct is too small, we perform a microincision at the cystic duct-CBD confluence.

Figure 2.

Longitudinal incision on the CBD.

Figure 3.

Placement of 3 and 9 o’clock stay sutures on CBD.

Regarding the stone extraction from the bile duct, we usually apply a Dormia basket (Figure 4), a balloon catheter or blunt forceps. After complete removal of the stones, multiple lavages of CBD in both directions by Nelaton tube and Fogarty catheter size 4–5-F should be done until the clear fluid was obtained. After the complete clearance of proximal and distal parts of CBD (Figures 5 and 6), the patency is confirmed by choledochoscopy or intraoperative cholangiography.

Figure 4.

Applying Dormia basket for stones extraction.

Figure 5.

Proximal lavage of CBD by Nelaton tube.

Figure 6.

Distal lavage of CBD by Nelaton tube.

Once all the stones are removed from the CBD (Figures 7 and 8), the incision of the bile duct should be closed over a T-tube or without it, with an interrupted 3/0 or 40 vicryl suture depending on the thickness of its wall (Figure 9).

Figure 7.

Gallstone into the CBD.

Figure 8.

Extraction of gallstone from the CBD.

Figure 9.

T-tube into the CBD with sutures placed around.

Many authors do not advocate the usage of T-tube after choledochotomy, because of the risk of postoperative infectious complications. Although a 12–14-Fr T-tube is indicated after choledochotomy, in the cases of excessive manipulation and trauma of CBD, extraction of more than five CBD stones or suspicion of residual stones.

After the closure of the cystic duct or CBD, retrograde cholecystectomy should be finished, and the gallbladder is removed with a specimen retrieval bag.

A 16-Fr drain was placed in the subhepatic region after thorough saline lavage of this region to exclude bile leakage in the postoperative period.

7. Postoperative care and patient’s follow-up

After the operation, the patients with LCBDE usually receive a broad-spectrum intravenous antibiotic for 48 hours in the postoperative period. If there is any evidence of sepsis or cholangitis (fever and elevated total leukocyte count), we continue the intravenous antibiotic treatment. If there is no sign of infection or sepsis, we start an oral antibiotic for five days.

In the early postoperative period, it is essential to continue the treatment of hypovolemia, to keep the fluid balance, especially in the case of T-tube after LCBDE. Avoidance of dyselectrolytemia and edema of the body, keeping stable blood pressure, pulse, and urine output, as well as sufficient nutritional support, are primordial for the correct management of these patients.

According to the literature, when the patient needs a radical operation after treatment of ERCP, PBD, or LCBDE, the operation can proceed if the total bilirubin level declines steadily by more than 30% for 2 weeks after the intervention, and it is not necessary for it to go down to normal. The biliary drainage was evaluated as effective if the total bilirubin level declines steadily by 20% for seven days at least [56].

8. Analysis of the results

In an effort to find out the best option for treatment of patients with high medical risk (e.g., AOC), a randomized, clinical trial was published comparing the outcomes of preoperative ERCP and subsequent laparoscopic cholecystectomy (LC)–as a two-stage procedure versus LCBDE + LC (as a one-stage intervention). The authors concluded that even though there was no difference between approaches regarding duct clearance, postoperative stay, early complications, or conversion in higher-risk patients, the LCBDE was more effective and efficient and avoided unnecessary procedures [62].

In a systematic review and network meta-analysis, the authors compare the efficacy and safety of four surgical approaches to CBD stones retrieval: preoperative ERCP and subsequent LC (two-stage procedure), LC + intraoperative ERCP (one-stage procedure), LC + postoperative ERCP (two-stage procedure), and LCBDE + LC (as a one-stage intervention). As a result, the authors draw the following conclusions: All approaches had similar results regarding overall mortality. LC plus LCBDE was the most successful for avoiding overall bleeding, for the shortest operative time and total cost. LC + intraERCP was the best approach for the length of hospital stay.

In general, LC + intraERCP approach is the safest and the most successful technique. LC + LBCDE appears to reduce the risk of acute pancreatitis but may be associated with a higher risk of biliary leak and biliary peritonitis [63].

According to the meta-analysis comprising 4224 patients, the authors compare the results after laparoscopic transcystic exploration (LTCE) of CBD and laparoscopic transductal exploration, by choledochotomy (LTDE) for extraction of CBD stones. They found out that a successful duct clearance occurred more often with LTDE than with LTCE. The analysis revealed no significant differences in the conversion to open procedures, total morbidity, operating time, or blood loss. Even though the LTDE has a longer duration of surgery and the patients have a longer hospital stay. There was also no significant difference in the postoperative bile duct stricture or reoperation observed. The higher risk of bile leak and early peritonitis after LTDE is the most frequent complication, which can be explained by the fact that bile duct suturing is a challenging task and has a significant learning curve [64]. According to the literature, the operation time of LCBDE decreases as the experience of the surgeon increases [50].

Another meta-analysis, comparing the results obtained from LTCE and LTDE approach, make the conclusion that LTCE access is safer and has lesser biliary complications [58].

Extraction of the CBD stones by transductal approach is the easier way, compared to the transcystic technique. At the same time, the risk of complications after choledochotomy is more important than the risk after the transcystic approach. That is why many authors prefer the transcystic technique in clinical practice [65, 66].

We perform choledochotomy by laparotomy and leave a T-tube in the CBD for more than 100 years. The reason for that is to decompress the CBD during the postoperative period and to check for retained stones by cholangiography [67]. Today many authors associate the placement of T-tube with complications after LCD [68].

Two meta-analyses published in 2020 and in 2021, with 1865 and 604 patients enrolled compare the results of primary duct closure (PDC) versus T-tube drainage (TTD) after LCBDE. Statistically, there were no significant differences in the early postoperative complication as bile leakage, retained stones or postoperative time between the TTD and PDC groups. According to this article, PDC is safe and effective and can be used as the first choice after transductal LCBDE in patients with cholelithiasis. The authors revealed significantly less hospital expenses calculated in the PDC group compared with the TTD group. Even the long-term complications after PDC, such as CBD stricture or retained stones, are shown to be insignificant [46, 69, 70, 71].

Today ERCP is the first-line treatment for choledocholithiasis with an overall procedural success–85.8%, according to the nationwide quality registry in the Netherlands. A study published in 2021, comparing the effect of treatment after LCBDE (as a first-line intervention) and LCBDE (after failed ERCP). In this meta-analysis, including 642 patients, the conclusion was that overall complications, bile leakage, conversion, and postoperative hospital stay were comparable in both groups. The overall procedural success of LCBDE, after failed ERCP, was more than 90%. The author notes that LCBDE is an alternative acceptable procedure when endoscopic therapy fails [72, 73].

Usually, the operation time of LCBDE range from 90 min. to 240 minutes according to the literature. The estimated blood loss during the operation was less than 200 mL, and no blood transfusion was required during any operation.

The percentage of conversion to laparotomy was negligible [70, 71, 72].

In all patients with choledochotomy and T-tube left in the CBD, the surgeon usually also place a drainage tube at the Winslow hole.

9. Conclusions

1. The overall success rate of LCBDE ranges from 91.8%. to 95% according to the published literature.

2. The laparoscopic intervention to choledocholithiasis is safe, cost-effective, and efficient approach means of returning the patient to his or her former lifestyle with the least financial or social disruption. This approach has been suggested as a comparatively effective approach for treating cholelithiasis and is included in the guidelines of the British Society of Gastroenterology for the treatment of choledocholithiasis [74].