Laparoscopy in cholecysto-choledocholithiasis...Cholecystolithiasis Choledocholithiasis abstract...

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Best Practice & Research Clinical Gastroenterology 28 (2014) 195–209

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Best Practice & Research ClinicalGastroenterology

16

Laparoscopy in cholecysto-choledocholithiasis

A.H. van Dijk, MD a, M. Lamberts, MDb,c,C.J.H.M. van Laarhoven, MD, PhD, Professor c,J.P.H. Drenth, MD, PhD, Professor b,M.A. Boermeester, MD, PhD, Professor a,P.R. de Reuver, MD, PhD a,*aDepartment of Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The NetherlandsbDepartment of Gastroenterology and Hepatology, Radboud University Medical Centre, Postbus 9101,6500 HB Nijmegen, The NetherlandscDepartment of Surgery, Radboud University Medical Centre, Postbus 9101, 6500 HB Nijmegen,The Netherlands

Keywords:LaparoscopyCholecystolithiasisCholedocholithiasis

* Corresponding author. Department of SurgeryNetherlands. Tel.: þ31 205962166; fax: þ31 20555

E-mail address: [email protected] (P.R. d

1521-6918/$ – see front matter � 2013 Elsevier Lthttp://dx.doi.org/10.1016/j.bpg.2013.11.015

a b s t r a c t

Gallstone disease is one of the most common problems in thegastroenterology and is associated with significant morbidity. Itmay present as stones in the gallbladder (cholecystolithiasis) or inthe common bile duct (choledocholithiasis). At the end of the1980s laparoscopy was introduced and first laparoscopic chole-cystectomy was performed in 1985. The laparoscopic technique forremoving the gallbladder is the current treatment of choice,although indications for open surgery exist. To perform laparo-scopic cholecystectomy as safe as possible multiple safety mea-sures were developed. The gold standard for diagnosing andremoving common bile duct stones is Endoscopic RetrogradeCholangiopancreatography (ERCP). The surgical treatment optionfor choledocholithiasis is laparoscopic cholecystectomy withcommon bile duct exploration. If experience is not available, thanERCP followed by elective cholecystectomy is by far the besttherapeutic modality. The present review will discuss the use,benefits and drawbacks of laparoscopy in patients with chol-ecystolithiasis and choledocholithiasis.

� 2013 Elsevier Ltd. All rights reserved.

, Amsterdam Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The9243.e Reuver).

d. All rights reserved.

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A.H. van Dijk et al. / Best Practice & Research Clinical Gastroenterology 28 (2014) 195–209196

Introduction

Gallstone disease (cholelithiasis) is one of the most common gastroenterological disorders, asso-ciated with significant morbidity and increasing costs.

Estimated prevalence is 10–20% in Europe and America [1]. Gallstones are the result from a dis-balance in the physical–chemical composition of bile.

In the Western world, approximately 70% of gallstone carriers have cholesterol gallbladder stones(cholesterol content >50%), and 30% have black pigment gallbladder stones. In East Asia, there istraditionally a high prevalence of brown pigment stones residing in the bile ducts associated with thehigh prevalence of cholangitis [2].

The majority of patients with gallstones remain asymptomatic. However symptoms of biliarycolic and complications such as cholecystitis, cholangitis and biliary pancreatitis are indications fortreatment [3].

Open to laparoscopic surgery

Cholecystectomy is generally accepted as the treatment of choice for symptomatic gallstonedisease and is one of the most frequently performed surgical procedures in the Western world. Thefirst successful procedure was performed in 1882 by Langenbuch. There has been gradualimprovement in surgical procedures to reduce pain and facilitate recovery. Therefore large openprocedures were abandoned and incisions were minimized. The small incision cholecystectomy wasintroduced by Dubois in 1982 [4]. During the 1980s attention focused on this minimal invasiveprocedure and several series reporting on alternative techniques followed. At the end of the 1980slaparoscopy was introduced and Mühe performed the first laparoscopic cholecystectomy (LC) inGermany in September 1985 [5].

No other surgical intervention was so quickly adopted as the LC without proper assessment ofoutcome in terms of safety and clinical outcome. Within five years time, LC was declared to be the goldstandard, although sufficient level of evidence for its superiority had not been provided. Numerousstudies, assembled in a Cochrane Systematic Review, have reported that LC results in a shorter hospitalstay, speedier recovery, reduction of postoperative pain, and better cosmetic results compared withopen surgery [6].

The present review will discuss the use, benefits and drawbacks of laparoscopy in patients withcholecystolithiasis and choledocholithiasis.

Cholecystolithiasis

Diagnostics in cholecystolithiasis

The typical presentation of a patient with uncomplicated cholecystolithiasis is a biliary colic. Thedefinition of a biliary colic is best described by the Rome criteria. These criteria define a biliary colic as atrias that consists of a steady pain, usually located in epigastrium and/or in the right upper quadrant,lasting 30 min or longer [7]. However, in routine clinical care patients often present with less typicalabdominal symptoms that are attributed to coexistent gallstones [8].

In a recent prospective cohort study neither biliary colic nor any other gastrointestinal symptomwas directly related to gallstone disease [9]. Therefore, the diagnosis of symptomatic chol-ecystolithiasis cannot be based solely on the presence of biliary colic.

The diagnostic tool of choice for cholecystolithiasis is abdominal ultrasound, with a sensitivity of0.81 (CI 0.75–0.87) and a specificity of 0.83 (CI 0.74–0.89) [10]. Other diagnostic modalities, such asendoscopy or computed tomography (CT), can help differentiate between uncomplicated gallstonedisease and other causes of abdominal symptoms in patients and should be used only when absolutelynecessary [11].

A.H. van Dijk et al. / Best Practice & Research Clinical Gastroenterology 28 (2014) 195–209 197

Indication for laparoscopic surgery

A standardized work-up and indication for surgery in cholecystolithiasis is lacking in internationalguidelines, which results in a variety of indications for cholecystectomy in general, among surgeonsand between countries [12]. Since the indication for gallbladder removal is not evidence based,additional randomized trials are necessary to optimize the indication for LC in cholecystolithiasis.

In a patient with complicated cholelithiasis (i.e. choledocholithiasis, acute cholecystitis, biliarypancreatitis or cholangitis) the indication for LC is clear, since morbidity and mortality are reduced bycholecystectomy.

In asymptomatic patients, the annual chance to develop complicated cholecystolithiasis is 1–2 %[13]. Also, of patients with asymptomatic gallstones a mere ten percent will develop symptoms in thenext five years [14]. Therefore, prophylactic cholecystectomy in this group is not recommended [11].

In patients with suspected symptomatic but uncomplicated cholecystolithiasis a LC is also oftenbeing performed. The main purpose of this operation in these patients is to relieve symptoms [15]. It isa challenge, however, to ascertain whether the symptoms are solely related to the presence ofgallstones.

Open cholecystectomy

The absolute indications for open cholecystectomy rather than the laparoscopic approach include[16,17]:

- Patients unable to tolerate a pneumoperitoneum due to haemodynamic instability or significantcardio-pulmonary comorbidity. Pneumoperitoneum in these patients may lead to cardiovascularcalamity.

- Patients suspected of a gallbladder malignancy or with gallbladder polyps larger than 1 cmwhichmay turn out to contain a malignancy. An open procedure is recommended to avoid gallbladderperforation and intraperitoneal dissemination of cancer cells.

- Patients with other intraabdominal pathology, making a laparoscopic procedure difficult orimpossible. This includes patients who are having a cholecystectomy as part of another surgery(e.g. Whipple).

- Patients with Mirizzi syndrome. Type I Mirizzi syndrome, consisting of extrinsic compression ofthe hepatic duct, can be treated laparoscopically by an experienced surgeon. Type II Mirizzi syn-drome, consisting of cholecystobiliary fistula, is a clear indication for an open procedure.

Techniques of laparoscopic cholecystectomy

The laparoscopic technique for removing the gallbladder is the current treatment of choice. In theUS 96% of all the cholecystectomies are performed laparoscopically [18].

Traditionally, four trocars are placed in the peritoneal cavity, in which the subumbilical incision isused for the camera trocar [8].

Over the years several alternative techniques have been developed, with the common goal ofminimizing post-operative pain, accelerating recovery and decrease scarring.

- Three-port laparoscopic colecystectomy has been reported. A meta analysis of randomized trialscomparing three-port with four-port laparoscopic cholecystectomy reported no significant dif-ference in operating time, post-operative pain or hospital stay. Cosmetic results and bile ductinjuries were not reported. However, the number of studies included in this meta-analysis is small,resulting in a low quality of evidence [19].

- An alternative laparoscopic treatment is the single-incision laparoscopic cholecystectomy (SILC).During SILC, multiple trocars are placed through the umbilicus using the fascia as a bridge betweenthe trocars. Alternatively, a single trocar port can be used [11]. Several disadvantages have been


described, such as difficult visualization. A recent systematic review showed a procedural failurerate for SILC ranging from 0 to 67 percent, significantly higher than for laparoscopic cholecys-tectomy. Duration of operation was significantly longer for the SILC procedure compared to con-ventional laparoscopy. For adverse events such as wound infections and port-site hernias nosignificant difference was found [20].

- A technique in development is the natural orifice transluminal endoscopic surgery (NOTES). InNOTES, surgery is performed via a natural orifice, like the vagina or stomach. It is less invasive anddecreases the need for abdominal incisions. It is thought to be safe and effective, with a bettercosmetic result and less post-operative pain. However, duration of operation is significantly longerthan in conventional laparoscopy [21]. In a recent three-armed randomized trial conventionallaparoscopy was compared to transvaginal and transumbilical NOTES. Cholecystectomy provedequally effective and safe in all three groups. However, the benefits and drawbacks of NOTES arestill scarcely scrutinized. As long as there is no clear evidence of benefit for this procedure, it’s notthe recommend therapy for patients with symptomatic cholelithiasis. More research is necessaryto implement this technique in usual practice [22].

Outcome of laparoscopic cholecystectomy versus open cholecystectomy

Outcomes of mortality and morbidity varied in different studies on cholecystectomy. LC is associ-ated with 0–0.2% overall mortality and 2–10.4% morbidity versus open cholecystectomy with a mor-tality rate of 0–0.5% and a morbidity rate of 4%–17.8% [8,23].

A recent reviewconcluded thatLCdoesnotdiffer significantly fromopencholecystectomywithrespectto mortality, complications, bile duct injuries, and operative time. LC does reduce postoperative pain andyields better cosmetic results and seems to be associated with significantly shorter hospital stay andearlier return towork (Table 1). However, this evidence is based on a high volume of low quality trials [6].

Procedure specific complications

General complications associated with LC include bleeding, intraabdominal infection, woundinfection or impaired wound healing. More specific complications include bowel injury and bile ductinjury (and bile leak).

- Significant bleeding during laparoscopy is uncommon and occurs in 0.5–1% [24].- In a large study discussing the outcome of LC, deep wound infections have been reported in 0.1%superficial wound infections in 1.1% and wound dehiscence in 0.1% [25].

- Injuries to the bowel from puncture by needle or trocar occur in up to 0.3% [8].

Outcome of laparoscopic cholecystectomy in cholecystolithiasis

The main purpose of cholecystectomy in this group is symptom relief. A recent review aimed toassess the effectiveness of elective cholecystectomy on persistent symptoms.

The most often reported persistent symptoms are diarrhoea and constipation; upper abdominalpain persists in up to 30 % of the patients [26]. In other studies a similar percentage is reported. Inpatients with non-gallstone specific symptoms, such as bloating, indigestion and acid reflux, the res-olution of symptoms by cholecystectomy is unlikely [27].

Outcome of laparoscopic cholecystectomy in acute cholecystitis

A randomized trial comparing different treatment options in acute cholecystitis concluded that LC issafe and effective, associated with lowmortality and morbidity. It is technically demanding and higherrates of conversion are seen, when compared to LC for uncomplicated gallstone disease [28].

Table 1A comparison of open versus laparoscopic cholecystectomy; randomized trials with more than 50 patients per group.

Trial Patients Outcomes Variable Author conclusions

[77] LC: 55OC:55

Hospital stayPost-op painSurgical timeComplicationsConversion(in patients withchronic liver disease)

- Hospital stay LC 1.9 days vs OC six daysa

- Painscore (VAS) 1st day LC 4.1 vs OC 7.9a

- Surgical time LC 76.1 min vs OC 96.1 mina

- Woundinfections LC 1.8% vs OC 18.2%a

- Deterioration of liver functionLC 5.5% vs OC 16.4%a

In LC shorter reducedhospital stay and feweroperative and post-opcomplications.Cholecystectomy in generalis associated with significantmorbidity compared withthat of patients withoutcirrhosis.

[78] LC: 50OC: 51

Recurrent symptomsPost-op painComplicationsSick leave

- Recurrent symptoms after 6–13 monthsLC 8% vs OC 11.7%a

- Complications LC 4.4% vs OC 2%a

- Need for analgesics LC 40% vs OC 86%a

- Full return to activity LC 12.8 days vs 35.9 daysa

Less recurrent symptoms inLC and faster return to fullactivity.Fewer complicationsin LC group.

[79] LC: 133OC: 131

ComplicationsHospital stayConversion(in patients 65years and older)

- Complications LC 13.5% vs OC 23.6%- Hospital stay LC 3.7 days vs OC 9.9 daysa

- Conversion necessary in 8.3%

LC has a lower rate ofcomplications and shorterhospital stay in elderlypatients when comparedto OC.

[80] LC: 50OC: 50

Respiratory function - PaO2 LC post-op 11.8 kPa vs OC 9.5 kPaa

- Respiratory rate post-op 18.5/min vs OC 20.8/minOC patients had statisticallysignificant disturbancesincluding hypoxia,hypocapnia andhyperventilation.

[81] LC: 60OC: 60

Hospital stayOperative timeCardio-respiratoryfunction

- Hospital stay LC 4.6 days vs OC 7.8 daysa

- Operation duration LC 86.6 min vs OC 81 mina

- PaO2 during operation LC 19.6 kPa vs 18.1 kPaa

LC postoperative(especially cardio-respiratory)changes are thereforequalitatively similar butsignificantly less marked thanthose seen with OC.

Post-op: post-operative; LC: laparoscopic cholecystectomy; OC: open cholecystectomy; VAS: visual analogue score.a A significant value with a p-value of


is greatly affected by the training and experience of the surgeon performing the surgery [34]. The rateof complications decreases as the number of operations the surgeon has performed increases [35]. Inrecent years technical innovations are emerging to complement surgical resident teaching pro-grammes. Several games and smartphone/tablet-apps have been developed to train starting physiciansin laparoscopic techniques [36].

Also, pre-operative and peri-operative checklists have been implemented to reduce morbidity andmortality in laparoscopic surgery. It may be necessary to use a checklist especially designed for lapa-roscopic surgery, because of the technical aspects that are unique to the laparoscopic approach [37].

A surgical strategy that has been developed by Strasberg is the ‘critical view of safety’ (Fig. 1) [38]. Ithas been proved to be extremely important and has shown to reduce bile duct injuries. The ‘criticalview of safety’ consists of three requirements. First, the triangle of Calot must be cleared of fat andfibrous tissue. The common bile duct (CBD) does not have to be exposed. Secondly, the lowest 1/3 of thegallbladder must be separated from the cystic plate. Thirdly, only two structures (cystic duct and cysticartery) must be seen entering the gallbladder. If these three requirements are met, the ‘critical view ofsafety’ has been accomplished [38,39].

Intra-operative cholangiography as a safety measurement

Intra-operative cholangiography (IOC) is another reported safety intervention suggested to mini-mize the incidence of bile duct injuries [39–43]. It is also used to diagnose common bile duct stones. Inthis technique a catheter is placed in the cystic duct laparoscopically with especially designedequipment and secured, for example with a clip. Then a contrast medium is injected and the IOC iscomplete when contrast fills the distal bile duct and enters the duodenum. Flow must be seen prox-imally to identify the left and right hepatic duct [44].

In LC IOC requires extra technical skill and may be technically unfeasible in patients with a severelyinflamed gallbladder or with a tiny or inflamed cystic duct. In these patients, but also in a generalpopulation undergoing LC, IOC is suggested to prevent bile duct injury.

The benefits of IOC in LC are still under discussion. Several groups advocate routine use of IOC,because IOC reduces and identifies bile duct injuries, and identifies asymptomatic CBD stones [45].However, there is no clear evidence for the prevention of BDI by using IOC. Opponents argue thatasymptomatic CBD stones may pass spontaneously and have a low potential for causing complications,such that their identification may lead to unnecessary CBD exploration and/or conversion to opensurgery [46]. The argument to use IOC in difficult cases fails as the interpretation of the cholangiographis often as hard to interpret as the actual anatomy. In these cases misinterpretation remains the maincause of injury.

A recent meta analysis by Ford et al identified eight randomized trials including 1715 patientsundergoing routine versus selective cholangiography. No trial demonstrated a benefit in detectingCBD stones, while IOC added a mean of 16 min to the total operating time. Based on these data theauthors conclude that there is no robust evidence to support or abandon the use of IOC to preventretained CBD stones or bile duct injury, since the evidence for IOC is of poor to moderate quality[47].

Conversion to open surgery

The range of conversion rates in literature is wide, most studies describe a percentage less than 10%.In patients with acute cholecystitis the conversion rate is significantly higher and ranges from 10 to 40%[30,48]. Reasons to convert to open procedure include a need for better visualization of the cystic andcommon bile duct due to inflammation, anatomic difficulty, uncontrollable bleeding, limited surgicalexperience or significant adhesions.

Multiple studies have described the risk factors for converting laparoscopic to open cholecystec-tomy, including obesity, adhesions in the gallbladder region (or previous abdominal surgery), malegender, old age and acute cholecystitis [17,48,49].

Conversion is not a complication of LC and should not be considered a failure in management [16].However, the surgical experience in performing an open procedure has been declining since the

Fig. 1. The critical view of safety.


introduction of LC. Young surgeons have little or no experience with conversion. In these cases con-version can lead to the occurrence of BDI instead of preventing it. It is therefore important to considergallbladder drainage or a partial cholecystectomy. Either way, surgery in the complicated gallbladderremains a matter for a specialized and experienced surgeon [33].

Partial cholecystectomy (subtotal cholecystectomy)

Partial cholecystectomy is a viable alternative to standard cholecystectomy in difficult circum-stances. It is most often used in the case of a ‘difficult’ gallbladder; e.g. in cholecystitis where identi-fication of the common bile duct and other anatomical structures is problematic due to adhesions/fibrosis or severe inflammation [50]. If CVS can not be obtained a change in strategy should be appliedto prevent injury. A partial cholecystectomy is a good and safe alternative.

Open partial cholecystectomy was first described in 1985 and has been used in laparoscopy since1993. In laparoscopic cholecystectomies the partial removal of the gallbladder offers an alternative forconversion [51].


A recent review identified several methods to perform laparoscopic partial cholecystectomy [51].The method most used involved excising the largest part of the gallbladder’s anterior wall, leaving theposterior wall attached to the liver. The remaining gallbladder stump can be closed. Essential duringthis procedure is the removal of remaining stones and it is advised to leave a drain if the closure of thestump is not achieved.

The most frequent complication reported was non-specified bile leakage (most often from a notclosed or not adequately closed cystic duct). Bile leakage from the cystic duct rarely leads to majorcomplications and usually resolves spontaneously [50]. If not, temporary biliary stenting can beapplied.

Another frequently described complication of partial cholecystectomy is the formation of newgallstones. This is a rare occurrence and was reported in 2–5% of all cases [51].

Fig. 2 shows two photo’s of a patient in whom severe cholecystitis was an indication for a partialcholecystectomy (Fig. 2(a)). Fig. 2(b) shows the remnant gallbladder after a follow-up of five years.Inflammationwas gone andcompletion of the cholecystectomywas indicateddue to return of symptoms.

Choledocholithiasis

Clinical features of choledocholithiasis

Symptomatic choledocholithiasis is defined as the presence of gallstones in the common bile ductwith associated symptoms [52]. These symptoms include dark urine, acholic stools, and jaundice. Theindication for further investigation of common bile duct stones is based on a combination of bothclinical, laboratory and radiological outcomes. A meta-analysis of cohort studies identified indicatorsfor choledocholithiasis [53]. The risk level of having common bile duct stones determines the diag-nostic or therapeutic strategy. Cholangitis, preoperative jaundice, and transabdominal ultrasono-graphic evidence of choledocholithiasis are indicators that suggest gallstones in the common bile duct.Each of these indicators predicts a high risk of choledocholithiasis. For a dilated common bile duct onultrasound (>8 mm), hyperbilirubinemia (>two-times normal range), and jaundice positive likelihoodratios range from almost four to almost seven. These single indicators predict an intermediate risk ofcommon bile duct stones. Finally, pancreatitis, cholecystitis, hyperamylasemia and elevated levels ofalkaline phosphatase have positive likelihood ratios of less than three and therefore predict a low riskcholedocholithiasis [53].

Additional imaging of choledocholithiasis

If suspected clinically, transabdominal ultrasonography is the first imaging modality of choice forcholedocholithiasis, despite a limited sensitivity [53,54]. While large common bile duct stones can bevisualized sonographically, small stones may be difficult to identify. In that case, additional imagingsuch as Magnetic Resonance Cholangio Pancreatography (MRCP) or Endoscopic UltraSonography (EUS)may be performed [55].

A systematic review of randomized trials directly comparing EUSwithMRCP showed no statisticallysignificant differences between themodalities [56]. If choledocholithiasis is clinically suspected despitea negative transabdominal ultrasound, additional MRCP or EUS should be based on factors such asresource availability, expertise, and cost considerations.

Endoscopic Retrograde Cholangiopancreatography (ERCP) is considered to be the gold standard fordetecting choledocholithiasis. It also offers the therapeutic possibility of extracting stones from the bileduct at the same time. However, ERCP is primarily indicated for biliary interventions. It is not a firstchoice imaging modality due to the potentially life threatening risks of complications, includingpancreatitis with an incidence rate of 5.3% [57].

ERCP should therefore only be performed in patients with having a high probability of chol-edocholithiasis or after a positive EUS or MRCP in patients with an intermediate risk of chol-edocholithiasis. ERCP may be safely avoided in two-thirds of patients with common bile duct stones byperforming EUS first. As a result the complication rate can be significantly reduced [58].

Fig. 2. a Severe acute cholecystitis. b: Remnant gallbladder five years after laparoscopic partial cholecystectomy.


Surgery for choledocholithiasis

In general, a cholecystectomy is indicated after removal of common bile duct stones and ifcholecystolithiasis is present radiographically. The optimal timing of conducting a cholecystectomyafter endoscopic sphincterotomy and bile duct clearance is yet unclear. Surgical removal of thegallbladder does lead to fewer deaths, fewer patients with biliary pain, fewer patients with recurrentjaundice and cholangitis, and fewer additional cholangiographies when compared to a wait-and-seepolicy after endoscopic sphincterotomy and bile duct clearance [59]. The major limitations of thereview are the relatively few trials, few patients, and low number of outcomes as well as method-ological weaknesses of the trials. One of the included randomized trials comparing a wait-and-seepolicy after endoscopic sphincterotomy versus laparoscopic cholecystectomy after endoscopicsphincterotomy concluded that a wait-and-see policy could not be recommended as standardtreatment. Of expectantly managed patients, 47% developed at least one recurrent biliary event and


37% needed cholecystectomy during two years of follow-up. No major biliary complications arose, butconversion rate high [60].

A recent randomized controlled trial comparing patients who received a LC within 72 h after ERCPto patients who received a LC 6–8 weeks after ERCP, significantly more recurrent biliary eventsoccurred in the delayed LC group. No differences were shown between groups in conversion rate,operating times, difficulties, or hospital stay [61].

However, patientswith significant comorbidities can be exposed to high riskswhen operated. Itmayseem reasonable to consider await-and-see policy for these patients if papillotomyhas beenperformed,since risks of an operative intervention may outweigh additional risks due to gallbladder stones [62].

Published data conclude otherwise. A randomized trial comparing a wait-and-see policy after ERCPversus an open cholecystectomy with common bile duct exploration (if necessary) concludes thatsurgery is preferable in high-risk patients. Less recurrent biliary events occurred in the surgery groupwith no significant differences in immediate morbidity or mortality [63]. Therefore, a prophylactic LCfollowing successful clearance of common bile duct stones versus a wait-and-see policy should becompared in patients considered at high-risk for surgery.

In at least 3% of the caseswith choledocholithiasis an ERCP is not successful [64]. In high-risk patientswith endoscopically complex or non-extractable common bile duct stones, biliary stenting can be asolution, but the considerable risk of cholangitis with this approach should be taken into account [65].

Two radiological procedures can also play a role in the treatment of choledocholithiasis if initialERCP fails. The radiological endoscopic rendezvous procedure or percutaneous gallstone extractionmay be feasible treatment modalities [66,67]. Randomized trials to investigate the position of theseoptions in the treatment of choledocholithiasis after unsuccessful ERCP are lacking. Therefore, the roleof these procedures remains to be elucidated.

Surgical techniques in choledocholithiasis

If ERCP is not successful or when choledocholithiasis is diagnosed during a cholecystectomy, it ispossible to surgically remove the gallbladder and concomitant common bile duct stones in one sessionby an open or laparoscopic cholecystectomy with common bile duct exploration. Common bile ductexploration includes transcystic stone extraction and choledochotomy. Stone extraction from the cysticduct is successful in 75% of the patients [68,69].

When transcystic stone extraction fails, choledochotomy can be performed. An open chol-edochotomy is a safe second choice with low morbidity and a high success rate when ERCP fails [70].

LC with laparoscopic common bile duct exploration has comparable morbidity and mortality withERCP followed by LC, but the hospital stay after a single stage procedure is shorter [70–72]. Even thoughLC with laparoscopic common bile duct exploration seems a good treatment option for chol-edocholithiasis, the procedure remains limited to experienced laparoscopic surgeons. As common bileduct exploration is becoming rare, technical complications are rising [73]. The flow chart shows theproposed treatment strategy for patients with symptomatic choledocholithias (Fig. 3).

Traditionally, the common bile duct is closed with T-tube drainage after choledochotomy. However,the insertion of the T-tube is not without complications, such as postoperative biliary leakage [68].Furthermore, patients may have to carry the drain for several weeks before removal. Primary closure ofthe common bile duct has shown to be a better alternative. Primary closure as compared to T-tubedrainage carries fewer postoperative complications, less operation time and a shorter hospital stay[74,75]. Fig. 4 shows a cholangiography after the common bile duct is closed with T-tube. No commonbile duct stones are seen in the dilated system.

Intra- or postoperative ERCP

Other treatment options for choledocholithiasis may be an ERCP performed during or after surgery.No differences were reported between ERCP preoperatively and intraoperatively regarding bile ductclearance, operative morbidity, conversion to an open procedure, and operation time [64,76]. Althoughintraoperative ERCP is associatedwith lower complications, decreased hospital stay, and lower hospitalcosts, this treatment option is rarely performed. Endoscopists need to have experience in performing

Fig. 3. Flow-chart. The treatment of symptomatic choledocholithiasis. It depends on available expertise whether to treat commonbile duct stones by Endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) or by LCfollowed with Common bile duct exploration (CBDE).


an ERCP in a supine patient and logistical difficulties arise concerning coordination of endoscopist andsurgeon schedules [64]. ERCP after cholecystectomy is as successful as laparoscopic choledochotomy,when transcystic stone extraction has failed [68,69]. The choice of extracting the stone intraoperativelyor to perform ERCP after cholecystectomy therefore depends on the experience of the surgeon.

In conclusion, if choledocholithiasis is suspected clinically, additional investigations should beconducted preoperatively to avoid the risk of a secondary operative intervention. If choledocholithiasis

Fig. 4. Intra-operative cholangiography.


has been diagnosed, a laparoscopic cholecystectomy with common bile duct exploration is a goodtreatment option, since the hospital stay is significantly shorter. However, this procedure is limited toonly the very experienced laparoscopic surgeon. If experience is not available, an ERCP followed by acholecystectomy is by far the best therapeutic modality.

Practice points

� Biliary colic is the typical presentation of symptomatic cholecystolithiasis, and consists of asteady pain, usually located in epigastrium and/or in the right upper quadrant, lasting30 min or longer.

� The main purpose of cholecystectomy in symptomatic but uncomplicated patients issymptom relief. The majority of patients are suitable candidates for laparoscopic treatment.However absolute indications for open procedure exist, such as suspected malignancy.

� Abdominal pain persists in up to 30% of patients undergoing an elective cholecystectomy forsuspected symptomatic cholecystolithiasis.

� Laparoscopic cholecystectomy does not differ significantly from open cholecystectomyregarding mortality, complications and bile duct injuries.

� Bile duct injury is a severe complication of cholecystectomy that should be evaluated andtreated by a multidisciplinary team.

� If critical view of safety can not be obtained during surgery, an alternative approach, e.g.partial cholecystectomy, is advised.

� If choledocholithiasis is suspected clinically, additional work-up should be donepreoperatively.

� ERCP followed by elective cholecystectomy is the first feasible therapeutic modality forcholedocholithiasis. If a surgeon experienced in this field is available, the best treatmentoption is laparoscopic cholecystectomy with common bile duct exploration.

Research agenda

� Indication for cholecystectomy in symptomatic patients needs to be further defined, sincegreat variety exists and success rates are not sufficient.

� Further research is necessary to asses whether drainage or primary LC is the optimal treat-ment in patients with acute cholecystitis.

� A randomized trial is necessary to assess the effectiveness of prophylactic LC followingsuccessful clearance of common bile duct stones versus a wait-and-see policy in patientsconsidered at high-risk for surgery.

� The place of percutaneous transhepatic cholangiography relative to ERCP in common bileduct exploration of complex biliary duct stones needs to be examined.

Summary

Galstones are one of the most common problems in the Western world and can present as chol-ecystolithiasis (stones in the gallbladder) and choledocholithiasis (stones in the common bile duct).

Cholecystolithiasis is typically presenting with a biliary colic and is diagnosed by abdominal ul-trasound. A standardizedwork-up and indication for surgery in cholecystolithiasis is lacking, especiallyin patients with uncomplicated symptomatic gallstones. Most patients are eligible for laparoscopicsurgery; however absolute indications for open surgery do exist.


Procedure specific complications include bleeding, intraabdominal infection, wound infection orimpaired wound healing, bowel injury and bile duct injury. Patients often report persistent symptomspost-operatively. To perform laparoscopic cholecystectomy as safe as possible several safety measureswere developed, such as the critical view of safety and intra-operative cholangiography.

Common symptoms in choledocholithiasis include jaundice, alcholic stools and dark urine.Abdominal ultrasound is the first imaging modality of choice, followed by Endoscopic RetrogradeCholangiopancreatography (ERCP) as the gold standard for diagnosing and removing stones in thecommon bile duct.

If choledocholithiasis is suspected clinically, additional investigations should be conducted pre-operatively as the risk on a secondary operative intervention can be avoided. If choledocholithiasis hasbeen diagnosed, a laparoscopic cholecystectomy with common bile duct exploration is the besttreatment option, since the hospital stay is significantly shorter and mortality and morbidity is com-parable to ERCP followed by elective cholecystectomy. However, if the necessary expertise is absent,ERCP followed by elective cholecystectomy is the first feasible therapeutic modality.

Conflict of interest statement

None.

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www.guidelines.internationalLaparoscopy in cholecysto-choledocholithiasisIntroductionOpen to laparoscopic surgery

CholecystolithiasisDiagnostics in cholecystolithiasisIndication for laparoscopic surgeryOpen cholecystectomyTechniques of laparoscopic cholecystectomyOutcome of laparoscopic cholecystectomy versus open cholecystectomyProcedure specific complicationsOutcome of laparoscopic cholecystectomy in cholecystolithiasisOutcome of laparoscopic cholecystectomy in acute cholecystitisBile duct injury (BDI)Laparoscopic cholecystectomy: safety measuresIntra-operative cholangiography as a safety measurementConversion to open surgeryPartial cholecystectomy (subtotal cholecystectomy)

CholedocholithiasisClinical features of choledocholithiasisAdditional imaging of choledocholithiasisSurgery for choledocholithiasisSurgical techniques in choledocholithiasisIntra- or postoperative ERCP

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Laparoscopy in cholecysto-choledocholithiasis...Cholecystolithiasis Choledocholithiasis abstract...

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