EGS SO07 - Laparoscopic retrieval of endoscopic lithotripsy basket aided by laser fragmentation: Case presentation and literature review

Abstract Background Large or impacted common bile duct (CBD) stones that cannot be removed by conventional endoscopic methods sometimes require endoscopic mechanical lithotripsy. A rare but feared technical complication related to this is basket entrapment, where the stone-basket complex cannot be separated from each other due to mechanical failure and becomes impacted within the CBD. We present a novel case of laparoscopic CBD exploration and antegrade laser fragmentation of impacted stone-basket complex, and perform a literature review pertaining to this topic. Method This is a case report from a single district general hospital with laparoscopic capabilities but no access to Spyglass. The operation began with fundus first subtotal cholecystectomy and the cystic duct was ligated with PDS endoloops. A choledochotomy was made and dilated to allow insertion of a 7.5 Fr cholangioscope. Through this, laser lithotripsy was undertaken which reduced the stone size and permitted disengagement of the stone from basket. The stone was retrieved via enlargement of the choledochotomy, while the basket and wire retrieved orally. We subsequently performed a literature review of Pubmed, Google Scholar, and Embase. Results Laparoscopic retrieval of an impacted basket was first described in 1993, with the basket found lodged in the gallbladder. The technique involved a large cholecystotomy, followed by removal of the basket, closure of the gallbladder, and then cholecystectomy. Our literature review yielded 5 case reports of laparoscopic retrieval of basket from the CBD. Three authors describe manual disengagement of the basket by laparoscopic manipulation of the wires, one describes capturing an impacted Dormia basket with a second Dormia basket, and one describes direct mechanical fragmentation and subsequent balloon trawl of the remaining debris. Conclusion To our knowledge, this is the first case report describing laparoscopic CBD exploration with concurrent laser fragmentation to facilitate retrieval of impacted stone-basket complex following mechanical lithotripsy failure. We propose that this is a viable option in centres without Spyglass or electrohydraulic lithotripsy, but where expertise for emergency laparoscopic CBD exploration exists.