Laparoscopic Common Bile Duct Exploration in a Rural Community

BackgroundThere has been a shift in the management of choledocholithiasis from laparoscopic common bile duct exploration to endoscopic retrograde cholangiopancreatography. This has led to an increase in hospital length of stay, costs, and specifically for rural hospitals, transfer to a tertiary center for ERCP. Given this shift of choledocholithiasis management to advanced GI endoscopists, general surgery residents are rarely performing laparoscopic transcystic common bile duct explorations.MethodsA retrospective study of 69 consecutive laparoscopic transcystic common bile duct explorations (LCBDE) performed by 2 general surgeons in a rural community over 5 years between 2017 and 2022. Primary outcomes included successful duct cannulation, successful stone clearance, instruments used, operative time, and significant complications (pancreatitis, bile leak, bleeding, bile duct injury). Specific technique for laparoscopic transcystic common bile duct exploration is outlined in Appendix 1.ResultsThere was a median age of 54 years (Range 17-91). There was successful cannulation in 97% and successful stone clearance in 82% of cases. In the vast majority of cases only a guide wire and biliary balloon dilation catheter were utilized to perform the procedure. Median operative time for laparoscopic cholecystectomy with cholangiogram was 40 minutes. Median operative time for laparoscopic cholecystectomy with cholangiogram and transcystic common bile duct explorations was 64 minutes (Range 39-168). Therefore, the median time added by performing LCBDE was 24 minutes There were no complications during laparoscopic transcystic common bile duct explorations.ConclusionsLaparoscopic transcystic common bile duct exploration can be safely, efficiently, and successfully performed with 0.035-inch Roadrunner PC guidewire, TAUT intraducer and an Advance Biliary Balloon Catheter. In order to shift the management of choledocholithiasis back to the general surgeon to decrease the length of stay and cost, there needs to be a change at the residency training level.