Medical Health Encyclopedia

Surgeons are now increasingly using laparoscopy plus an imaging technique called cholangiography instead of ERCP when common duct stones are suspected.The laparoscopic procedure for common duct stones should be performed only in centers where there is expertise. It generally proceeds as follows:

• The initial approach is the same as with laparoscopic cholecystectomy. Small incisions, one or two 10 to 12 mm (around half an inch) and three 5 mm (.20 inches), are made in the abdomen.
• A tiny opening is made in the cystic duct that connects the gallbladder to the bile duct, and a thin tube is introduced to perform a cholangiogram. (In this procedure, a dye is administered to reveal the stone's location on x-rays.)
• The procedure is typically used in combination with cholangiography, an imaging technique in which a dye is injected into the bile duct and x-rays are used to view any stones. Cholangiography reduces the risk for injury in the common duct.
• If stones are identified, the surgeon inserts a tube with an inflatable balloon that is used to widen the duct.
• Stones are usually retrieved or withdrawn from the duct either with the use of a balloon or with a tiny basket.
• If laparoscopy is unsuccessful, then ERCP or open surgery is performed.

Experts are debating whether the use of this procedure is better than ERCP. Many surgeons believe that laparoscopy is becoming safe and effective and should be the first choice. Still, laparoscopy for common duct stones should be performed only by surgeons experienced in this new and demanding technique.

Open Common Bile Duct Exploration (Choledocholithotomy)

Choledocholithotomy, or common bile duct exploration, is used to remove large stones or in cases when the duct anatomy is complex. In this procedure, the doctor carries out open abdominal surgery and extracts gallstones through an incision in the common bile duct. Routinely, a so-called T-tube is temporarily left in the common bile duct after surgery and the doctor x-rays the bile duct through the tube seven to ten days postoperatively to determine if any stones remain in the duct.

Lithotripsy for Common Bile Duct Stones

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Shock wave lithotripsy is an option in certain cases for bile duct stones that cannot be extracted.

• Mechanical Endoscopic Lithotripsy. Endoscopy with mechanical lithotripsy employs a tiny steel crushing basket, which is inserted through the endoscope and into the common bile duct. The basket opens to trap and then crush the stone. It is capable of crushing and removing very large stones. The overall success rate is 80 - 90%, although 20 - 30% of patients require more than one treatment.
• Extracorporeal Shock Wave Lithotripsy. Extracorporeal shock wave lithotripsy is an option in certain cases of bile duct stones as it is for stones in the gallbladder.