Laparoscopic Common Bile Duct Exploration. Lessons Learned After 200 Cases

Abstract Introduction Laparoscopic common bile duct exploration (LCBDE) is a reliable, reproducible and cost-effective treatment for common bile duct stones. Several techniques have been described for choledochotomy closure. Aims To present our experience and the lessons learned from more than 200 cases of LCBDE. Patients and methods Between January 1999 and July 2012, 206 patients with common bile duct stones underwent LCBDE. At the beginning of the series, we performed the closure of the CBD over a T-tube (36 patients), subsequently we favoured closure over an antegrade stent (133 patients), but due to a high incidence of acute pancreatitis in the last 16 patients we have performed primary closure. Results The 3 closure groups were matched for age and sex. Jaundice was the most frequent presentation. A total of 185 (88.5%) patients underwent choledochotomy, whereas in 17 (8.7%) patients the transcystic route was used. The group that underwent choledochotomy had a larger size of stones compared to the transcystic group (9.7 vs 7.6 mm). In the stented group we found an 11.6% incidence of pancreatitis and a 26.1% incidence of hyperamylasemia. In the primary closure group we found a clear improvement of complications and hospital stay. The increased experience of the surgeon and age (younger than 75) had a positive impact on mortality and morbidity. Conclusions Primary closure of the common bile duct after LCBDE seems to be superior to closure over a T tube and stents. The learning curve seems to have a positive impact on the outcomes, making it a safe and reproducible technique especially for patients aged under 75 years.