Use of rigid tubal ligation scope: Serendipity in laparoscopic common bile duct exploration.

AIM: To assess the feasibility, safety of rigid tubal ligation scope in laparoscopic common bile duct (CBD) exploration.
MATERIALS AND METHODS: Rigid nephroscope was used for laparoscopic CBD exploration until one day we tried the same with the rigid tubal ligation scope, which was passed easily into CBD both proximally and distally visualising the interior of the duct for presence of stone that were removed using endoscopic retrograde cholangiopancreaticography (ERCP) basket. This serendipity led us to use this scope for numerous patients from then on. A total of 62 patients, including male and female, underwent laparoscopic CBD exploration after choledochotomy with rigid tubal ligation scope between March 2007 and December 2012 followed by cholecystectomy. All the patients had both cholelithiasis and choledocholithiasis with minimum duct diameter of 12 mm. A total of 48 patients were given T-tube through choledochotomy and closed, and the remaining 14 patients had primary closure of choledochotomy.
RESULTS: There were no intra-operative complications in any of the patients like CBD injury or portal vein injury. Post-operatively graded clamping of T-tube was done and was removed after 15 days in the patients who were given T-tube. None had retained the stone after T-tube cholangiography, which was done before removing the tube. Mean duration of follow up was 6 months. No patients had any complaints during the follow up.
CONCLUSION: Laparoscopic CBD exploration is also feasible with rigid tubal ligation scope. With experienced surgeons, CBD injury is very minimal and stone clearance can be achieved in almost all patients. This rigid tubal ligation scope can be an alternative to other rigid and flexible scopes.

INTRODUCTION

In 1991, Petelin et al. first described laparoscopic surgery for common bile duct (CBD) stones. The technique has evolved since then and several studies have concluded that laparoscopic common bile duct exploration (LCBDE) procedures are superior to sequential endolaparoscopic treatment. Cholelithiasis occurs more frequently with advanced age[12] and is a common disease of the elderly. CBD stones occur in 15-20% of patients with cholelithiasis. Nearly 2-5% of the patients present with residual biliary stones after biliary tract surgery. Only 5.2-12% of cases are asymptomatic. With laparoscopic cholecystectomy (LC) becoming the gold standard for cholelithiasis, the treatment for CBD stone has changed and many options available include (A) transcystic LCBDE, (B) CBD exploration via choledochotomy, (C) Placement of an endobiliary stent, (D) post-operative endoscopic retrograde cholangiopancreatography (ERCP) and intra-operative ERCP and (E) Open CBD exploration. The advent of ERCP with endoscopic sphincterotomy (ES) avoids open CBD exploration reducing their morbidity and mortality.[3] ERCP also has a lot of complications especially in elderly patients with co-morbidity. LCBDE has all the advantages of minimal access and is also most cost effective compared with the other options.[456] LCBDE is done using flexible choledochoscope or rigid scopes. Most of them use rigid nephroscope, instead of flexible choledochoscope, getting good results since flexible choledoscope is very costly and maintenance is difficult. We were also using the rigid nephroscope for a year. Because of the national family control programme, tubal ligation scope is readily available in almost all centres and is readily and easily accessible. We have both the rigid nephroscope and rigid tubal ligation scope in our department. One day we used the other available scope, the rigid tubal ligation scope, which was passed easily into CBD both proximally and distally visualising the interior of the duct for presence of stones that were removed using ERCP basket. This serendipity led us to use this scope for numerous patients from then on. Hence, we present our experience of LCBDE using the rigid tubal ligation scope.

MATERIALS AND METHODS

A total of 62 patients, 20 male and 42 female, underwent LCBDE after choledochotomy with rigid tubal ligation scope between March 2007 and December 2012 followed by cholecystectomy. All patients had both cholelithiasis and choledocholithiasis with minimum duct diameter of 12 mm. For 22 patients who had pre-operative jaundice, high oral glucose, vitamin k, lactulose syrup, oral ursodeoxycholic acid were given for about a week and then taken for surgery. Intra-operative characteristics like time taken for surgery, CBD injury and injury to vital structures like portal vein, hepatic artery were taken into consideration.

Operative Procedure

Through a four port approach CBD is addressed first. After choledochotomy the rigid tubal ligation scope is inserted through the umbilical port [Figure 1] to visualise interior of the bile duct proximally till both the right and left hepatic duct interiors are visible [Figure 2], while the regular scope was introduced through epigastric port and manipulation of other instruments was not required. Next the rigid tubal ligation scope was introduced through the epigastric port, which is to the right of falciform ligament distally till ampulla of vater is visible with continuous irrigation while regular scope was introduced in the umbilical port. Any stones, which were found, were basketted out with the ERCP basket passed through the scope [Figure 3]. Then LC was done. While 48 patients were given T-tube through choledochotomy and closed, the remaining 14 patients had primary closure of choledochotomy.

Figure 1

Rigid tubal ligation scope is inserted through the umbilical port

Figure 2

Both right and left hepatic duct interiors are visible

Figure 3

Stones found were basketted out with ERCP basket passed through the scope

Analgesics were given only for a day. All patients were started oral diet on day 2 after surgery. Graded clamping was started on the third day and fully clamped by the fifth day and all the patients were discharged before day 7. They were asked to come after 15 days and removal of the T-tube was done after T-tube cholangiogram. All patients were followed up for a mean of 6 months.

RESULTS

There were no intra-operative complications in any of the patients like CBD injury or portal vein injury. Mean operative time was 146 min. Post-operatively patients were on minimal analgesia only for a day or two. Graded clamping of T-tube was done from day 3 and completely clamped by day 5 and patients were discharged within day 7 and the T-tube was removed after 15 days. T-tube cholangiography done before removal of T-tube in patients who had been given T-tube and ERCP done in the third week in patients who had primary closure of choledochotomy showed no retained stones. Mean duration of follow up was 6 months. No patients had any complaints during the follow up.

DISCUSSION

There is dispute regarding the optimal treatment for concomitant gallstones and CBD stone.[789] ERCP pre-operatively or post-operatively, prior to LC can be used to manage patients who have suffered from concomitant gallstones and CBD stone in the laparoscopic era.[610] There are several drawbacks of this approach even though this is effective and safe for removing the CBD stones. They are two hospital admissions, two periods of anaesthesia, increase in length of hospital stay and hospitalisation expenses. If intra-operative cholangiography in LC after successful ERCP shows CBD stones, surgeons will face the dilemma of depending on LCBDE, post-operative ERCP or traditional open choledochotomy. In addition, pre-operative ERCP can produce false-negative results, leading to the possibility of morbidity and mortality.[5678910] Post-operative ERCP can avoid the risk associated with pre-operative ERCP to patients without CBD stone, but it necessitates another surgical procedure when pre-operative ERCP fails to remove the CBD stone.[11] Both pre-operative and post-operative ERCP have some short-term and long-term complications. For instance, they may result in post-operative complications, including bleeding, perforation, pancreatitis and even death[12131415] and stenosis of the sphincter of Oddi, cholangitis associated with duodenal content reflux as long-term complications. Tranter and Thompson[3] reported that the combined morbidity rate ranged from 1% to 19% (median, 13%) for ERCP with endoscopic stenting (ES) followed by LC and from 2% to 17% (median, 8%) for LCBDE. However, we can avoid complications such as pancreatitis, stenosis of the sphincter of Oddi and cholangitis associated with duodenal content reflux in the process of LCBDE because sphincter of Oddi is preserved. ERCP is difficult for removing a large stone, for which choledochoscope or any rigid scope is useful and easier to inspect CBD. Similar studies by Sarkar et al. and Khan et al. have shown that rigid nephroscope is superior to flexible choledochoscope in removing large stones and is cost effective.

LCBDE is a demanding technique with a long learning curve,[16] which has replaced open CBD exploration. It must be performed with a variety of techniques under laparoscopy, which is a relatively complicated procedure. It has been reported that LCBDE can be performed during a single procedure and is superior to ERCP with LC in terms of patient risk and cost effectiveness.[317] It is considered to be a safe and efficient treatment for choledocholithiasis; it is associated with a high stone clearance rate ranging from 84% to 97%, a post-operative morbidity rate of 4-16% and a mortality rate of approximately 0-0.8%.[517181920] However, T-tube drainage has been routinely employed after choledochotomy to decompress the bile duct and decrease biliary complications.[2122] The cost of single-stage (LC + LCBDE) management was lower than those for two-stage (LC + ERCP) management.[7] Also other studies[2324] have shown the same. We performed LCBDE only through the choledochotomy method, for all the cases. Compared with the transcystic approach, choledochotomy approach is a demanding technique with a long learning curve, but multiple stones as well as large stones can be removed more easily, which cannot be done with the transcystic method. Even though time taken for surgery was bit longer at the initial of the learning curve, it can be gradually reduced with experience, which is also true in this study.

Due to limitations of flexible choledochoscope like high cost and unable to retrieve very big stones, many surgeons are using rigid nephroscope with good results.[2526] We were also using the rigid nephroscope for a year. Because of the national family control programme, tubal ligation scope is readily available in almost all centres and is readily and easily accessible. We have both the rigid nephroscope and the rigid tubal ligation scope in our department. One day we used the other available scope, the rigid tubal ligation scope; since then we have been using this scope in many patients achieving the same results as the rigid nephroscope.

CONCLUSION

LCBDE with LC in single stage is cost effective, safe even with the rigid tubal ligation scope with no complications seen in this study with use of the rigid scope. Even though time taken for surgery was bit longer, at the initial stages of the learning curve, it gradually reduced with experience. With experienced surgeons CBD injury is very minimal and stone clearance can be achieved in almost all patients. Because it is easily available, this rigid tubal ligation scope can be an alternative method providing results as good as the flexible choledochoscope or the rigid nephroscope.