Laparoscopic choledochotomy is a minimally invasive surgical technique performed to open the common bile duct (CBD) for the removal of obstructing stones or other pathological conditions. It has emerged as a safe and effective alternative to open surgery, offering patients faster recovery, less postoperative pain, shorter hospital stay, and reduced surgical morbidity. This procedure is most commonly indicated in cases of choledocholithiasis, where stones are lodged in the CBD and cannot be removed by non-invasive methods such as endoscopic retrograde cholangiopancreatography (ERCP).

Indications

The primary indication for laparoscopic choledochotomy is the presence of stones in the CBD that are not amenable to extraction by endoscopic or pharmacological methods. Other indications include:

Failed ERCP or sphincterotomy.

Presence of large or multiple stones in the CBD.

Concomitant gallbladder stones with CBD stones.

Strictures or anomalies within the bile duct requiring surgical exploration.

Situations where intraoperative cholangiography or laparoscopic ultrasound confirms obstruction.

Preoperative Considerations

Patients undergoing laparoscopic choledochotomy are evaluated with a thorough history, physical examination, and relevant investigations. Imaging modalities such as ultrasonography, magnetic resonance cholangiopancreatography (MRCP), and computed tomography (CT) scans are crucial in confirming the presence, size, and number of CBD stones. Liver function tests, complete blood counts, and coagulation profiles are routinely performed. Patients should also undergo cardiopulmonary assessment, as laparoscopic surgery requires pneumoperitoneum and general anesthesia.

Surgical Technique

The procedure is usually performed under general anesthesia with the patient in a supine or reverse Trendelenburg position. A standard four-port laparoscopic setup, similar to laparoscopic cholecystectomy, is employed.

Exploration of the CBD

After the gallbladder and biliary anatomy are identified, the common bile duct is exposed by dissecting the hepatoduodenal ligament. Care is taken to avoid injury to surrounding structures such as the hepatic artery and portal vein.

Choledochotomy Incision

A longitudinal incision of approximately 5–10 mm is made on the anterior surface of the CBD using laparoscopic scissors or hook cautery. The incision is carefully extended to allow the introduction of instruments without causing ductal injury.

Stone Extraction

CBD stones are retrieved using a variety of techniques:

Fogarty catheters or Dormia baskets to sweep stones.

Saline irrigation and suction to flush out smaller stones.

Choledochoscopy, when available, for direct visualization and extraction of residual stones.

Verification of Clearance

A laparoscopic choledochoscope or intraoperative cholangiogram is performed to ensure that the CBD is free of stones and that bile flow into the duodenum is unobstructed.

Closure of the CBD

The choledochotomy can be closed in one of two ways:

Primary Closure: The incision is sutured directly with fine absorbable sutures. This is increasingly preferred in uncomplicated cases.

T-Tube Drainage: A T-tube is inserted into the CBD to allow external bile drainage, decompression, and postoperative cholangiography. This is reserved for cases with residual doubts about duct clearance, fragile ducts, or inflammation.

Postoperative Care

Postoperative management includes:

Monitoring of vital signs, bile output (if T-tube placed), and drain fluid.

Administration of analgesics, antibiotics, and intravenous fluids.

Early ambulation and resumption of oral intake.

Follow-up imaging to confirm duct clearance if T-tube drainage is used.

Patients undergoing primary closure generally recover faster and may be discharged within a few days, while those with T-tubes may require prolonged monitoring.

Advantages of Laparoscopic Choledochotomy

Minimally invasive compared to open choledochotomy.

Shorter hospital stay and faster return to normal activities.

Less postoperative pain and better cosmetic results.

Direct visualization of bile ducts with choledochoscopy ensures thorough clearance.

Avoids repeated ERCP, which can carry risks of pancreatitis and perforation.

Complications

Though generally safe, laparoscopic choledochotomy carries certain risks:

Bile leakage from the suture line or T-tube site.

Stricture formation at the choledochotomy site.

Infection or cholangitis.

Retained or recurrent stones.

Injury to the hepatic artery, portal vein, or surrounding structures.

Prompt recognition and management of complications are essential for favorable outcomes.

Outcomes and Prognosis

With the advancement of laparoscopic techniques and instruments, laparoscopic choledochotomy has achieved outcomes comparable to open surgery, with fewer complications and quicker recovery. Studies show high success rates in stone clearance, especially when choledochoscopy is utilized. The recurrence of CBD stones can occur in some patients, necessitating long-term follow-up.

Conclusion

Laparoscopic choledochotomy represents a significant advancement in the surgical management of CBD stones. It provides a safe and effective option for patients where endoscopic methods fail or are not feasible. With proper patient selection, meticulous surgical technique, and postoperative care, this procedure offers excellent outcomes and improves the quality of life for patients with choledocholithiasis and related biliary conditions.