Impact of choledochoscopy on the management of choledocholithiasis. Experience with 499 common duct explorations at the Massachusetts General Hospital.

This report summarizes the experience with 144 choledochoscopic examinations performed in the course of 499 common bile duct explorations for stones. Routine choledochoscopy added 15--20 minutes to the operation and caused no complications. In 24% of the patients, additional stones were discovered with the choledochoscope after completion of routine bile duct exploration. In spite of this, the incidence of retained stones found postoperatively remained 4%, with or without choledochoscopy. The factors contributing to the failure of choledochoscopy, thus far, to prevent all retained stones are identified as inexperience of surgeons learning to perform biliary endoscopy, failure to scan the biliary tree systematically and thoroughly (including the left hepatic duct), and failure to reach the duodenum with the choledochoscope, meaning failure to see the lower segment of the common duct and ampullary orifice. With a modicum of experience and attention to detail, it should be possible to reduce considerably further the number of retained stones.