Laparoscopic transductal common bile duct exploration after previous laparoscopic cholecystectomy and failed endoscopic retrograde cholangiopancreatography: minimally invasive surgery technique

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Around 20% of patients with gallstones will have common bile duct (CBD) stones1,2. Management of CBD stones will typically involve a single-stage laparoscopic cholecystectomy with CBD exploration or a two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy1,3. When a patient presents with retained CBD stones after laparoscopic cholecystectomy, ERCP is preferred4. However, this procedure will fail in 3–16% of cases and multiple reattempts increase the risk of complications4,5. Alternative management options are limited, that is interventional endoscopic ultrasonography (EUS), laparoscopic or open CBD exploration, and percutaneous radiological extraction2,4,6,7. EUS requires experienced endoscopists and is often limited to tertiary centres8,9. Percutaneous options may be challenging in patients with raised BMI or ascites, and are associated with significant morbidity (10–20%), decreased quality of life, and mortality (6%)8. Surgical approaches are associated with a small risk of mortality and 17–37% morbidity8. In the video accompanying this article, laparoscopic transductal CBD exploration in a patient with a retained CBD stone after laparoscopic cholecystectomy and failed ERCP is demonstrated. Laparoscopic Transductal CBD exploration The case of a 66-year-old transgender male (female-to-male sex reassignment at 18 years) is presented. He had undergone previous laparoscopic cholecystectomy and, subsequently, two failed ERCP attempts to remove a retained CBD stone. Set-up and port insertion: Operating room arranged with the surgeon, assistant, and C-arm to the patient’s left. Six ports were inserted: two 10 mm (infraumbilical and right subcostal) and four 5 mm (subxiphoid, right flank, left flank, and epigastric). Dissection and exposure: Dense adhesions in the central and lower abdomen were carefully dissected to access the subhepatic space. Hook diathermy, a harmonic scalpel, and suction were used. The fatty peritoneal fold over the CBD was divided and bleeding supraduodenal vessels controlled. Cholangiogram and choledochotomy: The CBD was cannulated directly for cholangiogram, revealing a dilated CBD with a distal filling defect (Fig. S1). Transverse choledochotomy was performed through the cholangiogram hole and sludge was expressed from the CBD (Fig. S2). Stone removal: A 5 mm choledochoscope was inserted, identifying a large stone (1 × 1 cm) obstructing the CBD. The stone was removed using a zero-tip basket, requiring extension of choledochotomy. The ‘bog brush manoeuvre’ was performed, that is brushing up and down movements into the papilla with the basket, to remove residual debris. Inspection and closure: The choledochoscope was inserted proximally to inspect the second-order intrahepatic ducts, which were found to be clear of any stones. The choledochotomy incision was closed using multiple interrupted 3.0 Vicryl sutures. Postoperative saline lavage tested for patency and leaks. Final steps: A 14-Fr subhepatic drain was placed. Additional Chirocaine (0.25%, 20 ml) was injected into the subhepatic space. Ports were removed under direct vision. The linea alba was closed with 1.0 PDS and 3.0 Monocryl subcuticular skin sutures. Laparoscopic transductal exploration is a viable minimally invasive alternative procedure in retained CBD stones post-laparoscopic cholecystectomy when ERCP fails. Proper set-up, meticulous dissection, and careful closure are critical to avoid complications. Collaborative postoperative care for identification and management of complications is essential. Laparoscopic transductal CBD exploration is effective in a patient with a retained CBD stone after laparoscopic cholecystectomy and failed ERCP. The authors have no funding to declare. The authors declare no conflict of interest. Supplementary material is available at BJS online. The data that support the findings of this study are available from the corresponding author upon reasonable request.