Laparoscopic choledochoscopy with a small-caliber endoscope. A safe and effective technique for laparoscopic common bile duct exploration.

Incidental choledocholithiasis has been reported in 4-5% of cases during routine cholangiography. Many surgeons have resisted laparoscopic common bile duct exploration as a time-consuming and technically frustrating procedure, preferring to send the patient for postoperative ERCP. The purpose of this study was to objectively assess the safety, efficacy, and facility of transcystic duct choledochoscopy using a small-caliber choledochoscope with facilitated insertion technique. Twenty-five consecutive patients scheduled for laparoscopic cholecystectomy (LC) were studied prospectively. Choledochoscopy was carried out with a simplified introducer system using a 6.9-French choledochoscope. An arbitrary limit of 10 min was established for gaining access to the common bile duct (CBD). Incidental CBD stones were found in two of the 25 procedures (8%) and were cleared laparoscopically. The CBD was successfully entered in 21 of 25 attempts (84%). The average time for the entire procedure was 8.7 min. There were no procedure-related complications. Clinical application of this procedure was reviewed in a personal series of 742 LCs. Transcystic laparoscopic common bile duct exploration (LCDE) was successful in clearing stones from the CBD 75% of the time and the addition of laparoscopic choledochotomy brought the success of LCDE to 81%. Excluding patients where transcystic LCDE was not attempted, the overall success rate was 91%.