LAPAROSCOPIC EXPLORATION OF THE COMMON BILE-DUCT

Laparoscopic common bile duct exploration offers the possibility of complete minimal invasive therapy of biliary stone disease with respect to the anatomical structures of the papilla Vateri. In spite of generously indicated preoperative ERC, we found in 23 of 376 laparoscopic cholecystectomies unsuspected common bile duct stones by intraoperative in principle cholangiography. 8 patients with known common bile duct stones got a complete laparoscopic therapy. Balloon-dilatation of the ductus cysticus up to 5 mm is followed by laparoscopic choledochoscopy via the cystic duct. Small stones are washed into the duodenum or extraced retrogradely via the cystic duct. For bigger stones the intracorporeal lithotripsy is available, the stone scrap is washed either into the duodenum or is sucked off via the cystic duct. Laparoscopic choledochotomy is indicated for multiple big or proximally fixed stones. In this way stone extraction can be effectively performed, incarcerated stones are treated by additional lithotripsy. A microdrainage of the common bile duct or a T-tube drainage secures the bile flow until restitution of papillary function. The common bile duct is sewn by running suture. In the case of regular cholangiography the microdrainage can be removed on the third postoperative day. In 96 % of the laparoscopic cholecystectomies intraoperative cholangiography was possible. 3 of 21 patients with transductus cysticus-exploration had to undergo postoperative EPT due to residual stone fragments. 6 laparoscopic choledochotomies showed the efficacy of the endoscopic operation technique, demonstrating the probability of complications in the postoperative period to be equivalent to that of' conventional operations. Because of one step curative treatment and maximal care not only of the body integuments but also of the papilla Vateri complete laparoscopic therapy is advisable for common bile duct stones, but high demands are made on the technical equipment and the training of the surgeon.