BACKGROUND
Laparoscopic common bile duct exploration is an accepted alternative to laparoscopic cholecystectomy with endoscopic retrograde cholangiopancreatography (ERCP) and is of particular use in those patients who are unable to undergo ERCP for whatever reason as an alternative to open surgery.1,2 Recent UK guidelines recommended laparoscopic common bile duct exploration as the treatment of choice for patients with common bile duct stones undergoing laparoscopic cholecystectomy.3 Commonly, stones are retrieved using a choledocoscope and Dormier basket technique; however, this technique can prove inadequate for management of particularly large stones impacted at the ampulla.
TECHNIQUE
Standard laparoscopic cholecystectomy with on-table cholangiogram via the cystic duct is performed. Where the on-table cholangiogram or pre-operative imaging suggests an impacted large stone, a longitudinal choledochotomy is made and the findings confirmed on choledochoscopy. Where it proves impossible to remove the stone with a Dormier basket, the stone can be crushed using a Lithocrush Mechanical Lithotriptor (Olympus UK Ltd). Whilst it is not possible to pass this device down the 3-mm working channel of a choledochoscope, it can be inserted into the abdomen through a 5-mm port and then passed into the common bile duct through the choledochotomy alongside the choledochoscope (Fig. 1). The stone is then grasped with the lithotriptor under direct vision and crushed into small fragments which can then be extracted with ease using the Dormier basket (Fig. 2). After confirming that the duct is clear, the choledochotomy is closed in a standard manner.
Figure 1.
Demonstration of the set-up with the mechanical lithotripsy device inserted within the common bile duct alongside the choledochoscope.
Figure 2.
Stone fragments being withdrawn using the Dormier basket.
DISCUSSION
Our method for managing impacted large common bile duct stones with a mechanical lithotripsy device provides an acceptable alternative to open surgery for patients unable to undergo ERCP.
References
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