D E Wenner1, P Whitwam, J Rosser, S Hashmi, D E Wenner1. 1. Department of Surgery, Eastern New Mexico Medical Center, 405 West Country Club Road, Roswell, New Mexico 88201, USA. wwwt@dfn.com
Abstract
BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) has proved to be a safe, cost-effective way to treat common bile duct (CBD) stones. Despite this, LCBDE has not gained widespread adoption by surgeons. The technique has proved difficult to master, and damage to the fragile choledochoscope by grasping forceps and passage through the port valves has been problematic. Cases involving large, impacted, or multiple stones have required conversion to open exploration of CBD. METHODS: The Multichannel Instrument Guide (MIG) is introduced as a solution for these problems. The MIG is a J-shaped plastic extrusion with three lumens. It is flexible and can be straightened for insertion through a 10-mm port. The MIG facilitates insertion of a flexible 2.8- to 3.2-mm choledochoscope into the CBD. At the same time, additional tools such as balloon or irrigation catheters and lithotripters can be introduced into the CBD. These can be manipulated under video guidance via the choledochoscope. This procedural multitasking allows for a more efficient LCBDE. The authors describe their initial experience using the MIG for 23 patients. RESULTS: Of the 23 patients who underwent LCBDE procedures, 20 had stones in the CBD. Multiple stones were present in 48% of the patients; impacted stones were present in 26% of the patients; and stones larger than 1 cm were present in 26% of the patients. A 95% stone clearance rate was achieved. Difficult cases with large, impacted or multiple stones were resolved using the MIG. Two choledochoscopes were damaged; one during surgery and one during cleaning and storage. CONCLUSIONS: The MIG has demonstrated significant advantages over previously described techniques. The device secures biliary tract access and allows procedural multitasking while protecting the delicate and expensive equipment. Subsequently, a simplified technique algorithm can be followed that may encourage more surgeons to adopt the routine performance of LCBDE.
BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) has proved to be a safe, cost-effective way to treat common bile duct (CBD) stones. Despite this, LCBDE has not gained widespread adoption by surgeons. The technique has proved difficult to master, and damage to the fragile choledochoscope by grasping forceps and passage through the port valves has been problematic. Cases involving large, impacted, or multiple stones have required conversion to open exploration of CBD. METHODS: The Multichannel Instrument Guide (MIG) is introduced as a solution for these problems. The MIG is a J-shaped plastic extrusion with three lumens. It is flexible and can be straightened for insertion through a 10-mm port. The MIG facilitates insertion of a flexible 2.8- to 3.2-mm choledochoscope into the CBD. At the same time, additional tools such as balloon or irrigation catheters and lithotripters can be introduced into the CBD. These can be manipulated under video guidance via the choledochoscope. This procedural multitasking allows for a more efficient LCBDE. The authors describe their initial experience using the MIG for 23 patients. RESULTS: Of the 23 patients who underwent LCBDE procedures, 20 had stones in the CBD. Multiple stones were present in 48% of the patients; impacted stones were present in 26% of the patients; and stones larger than 1 cm were present in 26% of the patients. A 95% stone clearance rate was achieved. Difficult cases with large, impacted or multiple stones were resolved using the MIG. Two choledochoscopes were damaged; one during surgery and one during cleaning and storage. CONCLUSIONS: The MIG has demonstrated significant advantages over previously described techniques. The device secures biliary tract access and allows procedural multitasking while protecting the delicate and expensive equipment. Subsequently, a simplified technique algorithm can be followed that may encourage more surgeons to adopt the routine performance of LCBDE.
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