laparoscopic common bile duct exploration using a rigid nephroscope

Original article

Laparoscopic common bile duct exploration using a rigidnephroscope

S. Sarkar, S. Sadhu, T. Jahangir, K. Pandit, S. Dubey and M. K. RoyDepartment of General Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, 124, Mukundapur, E. M. Bypass, Kolkata700099, IndiaCorrespondence to: M. K. Roy (e-mail: [email protected])

Background: Patients with cholelithiasis and choledocholithiasis are increasingly managed withlaparoscopic bile duct exploration and cholecystectomy. Large impacted bile duct stones continueto defy laparoscopic extraction. This study explored the feasibility of laparoscopic bile duct clearanceusing a rigid nephroscope, which is suited to extracting large stones.Method: This prospective study recruited patients with large bile duct stones and a bile duct wider than8 mm on ultrasonography. In addition to standard ports for laparoscopic cholecystectomy, a custom-made 9-mm port was introduced in the epigastrium for the rigid nephroscope, which was negotiatedinto the bile duct through a choledochotomy. Rigid graspers and lithotripters were introduced throughthe nephroscope to fragment and remove the calculi.Results: Between December 2005 and September 2008, 18 patients had nephroscope-guided bile ductexploration (mean(s.d.) age 49(13·9) years, bile duct diameter 11·3(2·3) mm). Three patients had solitarystones and 15 had multiple calculi. Most of the stones were removed with graspers, but the lithotripterwas required in five patients. The mean(s.d.) hospital stay was 6(2·3) days. Two patients requiredpostoperative endoscopic retrograde cholangiopancreaticography for residual stones.Conclusion: The rigid nephroscope was useful for laparoscopic bile duct exploration, particularly forlarge impacted stones.

Paper accepted 16 January 2009Published online in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.6579

Introduction

Patients with cholelithiasis and choledocholithiasis aretraditionally treated with endoscopic retrograde cholan-giopancreaticography (ERCP) and removal of commonbile duct (CBD) stones followed by laparoscopic chole-cystectomy at a later date. In the current era of min-imally invasive surgery, there has been a considerableinterest in simultaneous CBD exploration and chole-cystectomy using laparoscopic techniques. Randomizedstudies have shown equivalent success rates and patientmorbidity between the two management options1. Laparo-scopic exploration of the CBD is commonly performedeither through the transcystic route2 or by supraduodenalcholedochotomy3. The former approach is possible withsmall stones but choledochotomy is preferred for large ormultiple stones.

One-stage bile duct clearance has prompted increasingenthusiasm for laparoscopic CBD exploration, which

has been reported to be successful in 85–95 per centof patients4,5. Large impacted stones, which cannot bedislodged easily, are a common reason for failure6. Thisis because of the limiting factor of the size of the Dormiabasket and the inability to dislodge stones impacted in thelower end of the CBD. Moreover, the narrow operatingchannel of flexible choledochoscopes precludes using wideinstruments to grasp large stones.

Rigid nephroscopes are commonly used by urologists forpercutaneous nephrolithotomy. The operating channel isdesigned to accommodate wide graspers and lithotripters.The nephroscope is widely available and could beused to perform CBD exploration. The aim of thisstudy was to assess the feasibility of rigid nephroscope-guided laparoscopic CBD exploration and to give abrief description of the initial experience using thisapproach.

Copyright 2009 British Journal of Surgery Society Ltd British Journal of Surgery 2009; 96: 412–416Published by John Wiley & Sons Ltd

Bile duct clearance using a rigid nephroscope 413

Methods

Patients with cholelithiasis and CBD stones were evaluatedin collaboration with a gastroenterologist and a radiologist.The diameter of the CBD, as measured by transabdominalultrasonography, was the most important deciding factorfor selecting patients for this prospective study. As the sizeof the rigid nephroscope is about 24 Fr, only patients witha CBD diameter of more than 8 mm were selected forlaparoscopic bile duct exploration. The options availablefor CBD clearance were explained, and informed consentwas obtained.

In the rigid nephroscope approach, four ports wereintroduced for standard laparoscopic cholecystectomy.After preliminary dissection, the cystic artery and ductwere clipped in the usual way. The cystic duct was nottransected at this stage. Sustained cranial traction on thegall bladder prevented Hartmann’s pouch from fallingover the CBD and kept the bile duct clearly visible forthe rest of the procedure. The first part of the duodenumwas moved away from the lower part of the CBD. Theareolar tissue overlying the CBD was cleared with gentledissection and a small longitudinal incision was made onthe CBD with a Dubois hook using monopolar diathermy.The choledochotomy was then enlarged with scissors. Acustom-made 9-mm port (Fig. 1) was introduced into theepigastrium, just below the costal margin, and midwaybetween the midline epigastric and the mid-clavicularport (Fig. 2). Through this port, a 24-Fr (12°) rigidnephroscope (Richard Wolf, Knittlingen, Germany) wasintroduced and negotiated through the choledochotomyunder laparoscopic guidance (Fig. 3). The nephroscopewas then attached to a second imaging system. Continuoussaline irrigation through the nephroscope distended theCBD and enabled clear vision of the CBD lumen (Fig. 4).Standard bi- or triprong forceps were introduced throughthe operating channel of the nephroscope and were usedto grasp the stones (Fig. 5). If the stones were impacted,they were fragmented with a pneumatic lithotripter (SwissLithoclast; Electro Medical Systems, Nyon, Switzerland)and removed piecemeal with graspers. On successfulextraction of the stones, the ampulla was clearly visiblefrom within (Fig. 6). The nephroscope was then negotiatedcranially towards the biliary hilum, and any remainingstones were dealt with in a similar manner. After this, thecarina and the origin of the right and left hepatic ductswere clearly seen (Fig. 7).

At this stage the cystic duct was transected andcholecystectomy was performed in the usual way. In theearly operations, the choledochotomy was closed over a Ttube, which was brought out through the wound of themid-clavicular port. However, with increasing experience,

Fig. 1 Custom-made 9-mm port

Fig. 2 Position of operating ports

Fig. 3 Rigid nephroscope

it became usual practice to close the choledochotomy withinterrupted 3/0 polyglycolide sutures after ascertainingcomplete clearance of CBD stones. A tube drain was

Copyright 2009 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2009; 96: 412–416Published by John Wiley & Sons Ltd

414 S. Sarkar, S. Sadhu, T. Jahangir, K. Pandit, S. Dubey and M. K. Roy

Fig. 4 A solitary stone in the common bile duct

Fig. 5 A common bile duct stone held in a triprong grasper

routinely introduced into the subhepatic space and broughtout through the anterior axillary port wound. In thepostoperative period, the decision to remove the drainwas guided by the clinical progress of the patient.

Results

Between December 2005 and September 2008, 18patients had laparoscopic CBD exploration with a rigidnephroscope (Table 1).

Fig. 6 View of the ampulla

Fig. 7 View of the carina

In most patients the stones were retrieved successfullywith bi- or triprong graspers. Occasionally the graspersfractured the stones, and the fragments were removedpiecemeal. In two patients, while attempting to grasp thefragments, the pieces were inadvertently pushed into theduodenum.

After CBD clearance, the choledochotomy was closedover a T tube in the first three patients and closed primarilyin the next 15 patients. Bile leaks, indicated by the presenceof bile in the subhepatic drain, occurred in four of the 15


Bile duct clearance using a rigid nephroscope 415

Table 1 Patient characteristics

No. of patients (n = 18)

Sex ratio (M : F) 6 : 12Age (years)* 49(13·9)Diameter of common bile duct (mm)* 11·3(2·3)No. of common bile duct stones

1 3> 1 15

Use of lithotripter 5

Choledochotomy closureT tube insertion 3Primary closure 15

Duration of postoperative hospital stay (days)* 6(2·3)Residual common bile duct stones 2

*Values are mean(s.d.).

patients. In three of these, transabdominal ultrasonographydid not reveal any intraperitoneal collection, but theother one had significant subhepatic and pelvic collectionsrequiring percutaneous drain placement. All patients withbiliary leak settled spontaneously.

The patients were routinely followed for 2 months.They were given an open appointment in order to reportany abdominal pain, jaundice or fever. Two patientshad residual stones, which were successfully removed bypostoperative ERCP. The first patient had originally hadmultiple stones and debris; the residual stones appearedon the postoperative T tube cholangiogram. The secondpatient, who had required lithotripter fragmentation,presented 6 months after surgery with obstructive jaundice.

Discussion

This study showed that the rigid nephroscope, routinelyused in most hospitals by urologists for percutaneousnephrolithotomy, is an excellent tool for extractinglarge bile duct stones. Despite its rigidity, intermittentaxial rotation of the 12° instrument allows satisfactoryvisualization of the bile duct from the ampulla to thecarina. In two patients, the transverse mucosal folds of thesecond part of duodenum were seen through the ampulla.

The only patient with a residual stone in the immediatepostoperative T tube cholangiogram had originally hadmany CBD stones. A T tube was inserted because ofsuboptimal visualization of the bile duct owing to stonefragments and debris. During the follow-up, only onepatient presented with jaundice after 6 months, and ERCPshowed a small stone at the lower end of the CBD.This patient had required lithotripter fragmentation. Itis common to find small stone fragments floating awayfrom the field of vision because of the continuous saline

irrigation through the nephroscope. This could be a reasonfor missing small stone fragments.

The evolution of minimally invasive techniques hasprompted increased enthusiasm for one-stage laparoscopicCBD exploration which has been reportedly successful in85–95 per cent of patients4,5. Bile duct clearance usingthe transcystic approach with a Dormia basket is mostuseful for stones smaller than 5 mm and for a CBD with adiameter smaller than 6 mm2. Choledochotomy and stoneclearance is performed by a Dormia basket or by a Fogartycatheter, which is manipulated to a point beyond the stoneand gradually withdrawn3. Subsequent choledochoscopythrough the choledochotomy ensures higher clearancerates than the transcystic approach7. The choledochotomyis conventionally closed with the insertion of a T tube orlately by primary closure, which has been reported to beas safe7,8. However, primary closure of a choledochotomyin a CBD with a diameter smaller than 5 mm is related topostoperative stricture9, and therefore is suggested to besafe only if the diameter is more than 7 to 9 mm8,10.

Large impacted CBD stones continue to defy laparo-scopic extraction. In one study with 60 patients laparo-scopic exploration failed in six, and all these patientshad impacted stones6. This is because of lack of ‘space’inside the CBD and inability to introduce strong graspersthrough the narrow choledochoscope. In such difficult sit-uations, further laparoscopic manoeuvring is aborted andeither postoperative ERCP is considered10 or the opera-tion is converted to traditional laparotomy6. IntraoperativeERCP as an option has not gained widespread accep-tance owing to logistical difficulties and increased costs11.With the choledochoscope inside the CBD, lithotripsyhas been performed either by introducing a Holmiumlaser12 or by electrohydraulic lithotripter13 through thecholedochoscope. These accessories are not easily avail-able because they are expensive and relatively fragile.High-energy extracorporeal lithotripsy, followed by ERCPand fragment extraction, also finds scant mention but isreportedly successful in 90 per cent of patients14. Manyof these sophisticated treatment options are not availableeverywhere.

The nephroscope is robust and is easily available, evenin resource-constrained hospitals. It accommodates widegraspers, thereby making it possible to extract large stones.In contrast, flexible choledochoscopes are fragile and,in one study with 23 patients undergoing laparoscopicCBD exploration, two choledochoscopes were damagedby the end of the study15. However, the nephroscopefeels cumbersome at first, and the rigidity makes itdifficult to negotiate the lower end of CBD to see theampulla, a prerequisite for successful clearance. In order


416 S. Sarkar, S. Sadhu, T. Jahangir, K. Pandit, S. Dubey and M. K. Roy

to achieve this, the nephroscope is manipulated to bringits longitudinal axis in line with the long axis of the bileduct, and the handle of the nephroscope is brought closertowards the anterior abdominal wall. This manoeuvre liftsup the lower end of the CBD and makes it possible to see theampulla. Unfortunately, this movement stretches the distalend of choledochotomy, which often gets extended beyondthe inferior end of the original incision. To facilitate safeclosure of the extended choledochotomy, it is prudent tomove the first part of duodenum at the very outset.

The readily available rigid nephroscope is a usefuladjunct to the ensemble of instruments required to performlaparoscopic CBD exploration. The operating channelaccommodates wide graspers and lithoclasts, and therebyhas the potential to become indispensable for extractinglarge impacted bile duct stones. Initial results from thisfeasibility study are encouraging, and the technique maymerit wider application.

Acknowledgements

The authors thank Dr S. Bajoria, Senior Urologist, formaking them familiar with the use of the rigid nephroscope.The authors declare no conflict of interest.

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laparoscopic common bile duct exploration using a rigid nephroscope

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