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Laparoscopic Gallbladder and Bile Duct Surgery

Laparoscopic biliary surgery has been one of my interests since my appointment in 1997. I am a “high volume-gallbladder surgeon” (more 150 cases a year). Please see below North West London Hospitals 6 months audit showing number of cases per surgeon (I am surgeon number 1).

My conversion has been 0 percent since 2002 (13 years) being the patient converted published as a case report of Choledochal Varices (Int Surg 2003.Apr-Jun 88 (2):76-9), it is also worth mentioning that despite the lack of conversion since then, I am doing the more complex cases in the trust with an average 30 laparoscopic bile duct explorations per year. My rate of bile duct injury is one case in more than 2500 (well below the average)

Secondary to my interest in laparoscopic biliary surgery, since 1999, in order to treat patients with stones also in the main bile duct, I have developed a laparoscopic bile duct exploration practice, with more than 250 cases until now, that has been published in several peer-reviewed journals .

Laparoscopic bile duct exploration is a valid alternative to ERCP (the removal stones from the mouth with an endoscope) for the management of CBD stones, with less mortality in the under-75 age group (0% in my experience), compared with an average 0.8% mortality in the ERCP group (see chart below), LCBDE data (blue) is my own data.

In the group of patients older than 75, this changes with an own audited mortality of 6%, so I try only to perform it when there is no other option and ERCP has failed, but also the ERCP mortality in this group is also higher, so cases need to be individualized, but, in principle, in this age group, ERCP should be the preferred option, sometimes without a cholecystectomy.

Laparoscopic bile duct exploration is a fascinating field that now in my hands has a 99% success rate, this has been recently helped with the introduction of the Holmuin laser for the lithotripsy of impacted stones. This non only helps fragmenting the stones using the choledochoschope (special tiny scope introduced from one of the ports) through a choledochotomy (small incision in the bile duct) allowing the view I show next

View of stone in CBD with choledochoschope (see video gallery)

The use of the Holmiun laser lithotripsy also allows the extraction of large stones from the cystic duct (see video gallery), that is the natural connection between gallbladder and bile duct, thus not requiring any special closure and minimising the risk of bile leak that in case of choledochotomy is around 2-3%

As an average patients following bile duct exploration stay 2-3 days in hospital and only one day if this is perform through the cystic route.