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Ann R Coll Surg Engl. 2009 May; 91(4): 347–348.
PMCID: PMC2749413
Technical Notes and Tips
Bruce Campbell, Section Editor

The Use of a Mechanical Lithotripsy Device as an Adjunct to Common Bile Duct Exploration

BACKGROUND

Laparoscopic common bile duct exploration is an accepted alternative to laparoscopic cholecystectomy with endoscopic retrograde cholangiopancreatography (ERCP) and is of particular use in those patients who are unable to undergo ERCP for whatever reason as an alternative to open surgery.1,2 Recent UK guidelines recommended laparoscopic common bile duct exploration as the treatment of choice for patients with common bile duct stones undergoing laparoscopic cholecystectomy.3 Commonly, stones are retrieved using a choledocoscope and Dormier basket technique; however, this technique can prove inadequate for management of particularly large stones impacted at the ampulla.

TECHNIQUE

Standard laparoscopic cholecystectomy with on-table cholangiogram via the cystic duct is performed. Where the on-table cholangiogram or pre-operative imaging suggests an impacted large stone, a longitudinal choledochotomy is made and the findings confirmed on choledochoscopy. Where it proves impossible to remove the stone with a Dormier basket, the stone can be crushed using a Lithocrush Mechanical Lithotriptor (Olympus UK Ltd). Whilst it is not possible to pass this device down the 3-mm working channel of a choledochoscope, it can be inserted into the abdomen through a 5-mm port and then passed into the common bile duct through the choledochotomy alongside the choledochoscope (Fig. 1). The stone is then grasped with the lithotriptor under direct vision and crushed into small fragments which can then be extracted with ease using the Dormier basket (Fig. 2). After confirming that the duct is clear, the choledochotomy is closed in a standard manner.

Figure 1
Demonstration of the set-up with the mechanical lithotripsy device inserted within the common bile duct alongside the choledochoscope.
Figure 2
Stone fragments being withdrawn using the Dormier basket.

DISCUSSION

Our method for managing impacted large common bile duct stones with a mechanical lithotripsy device provides an acceptable alternative to open surgery for patients unable to undergo ERCP.

References

1. Martin DJ, Vernon DR, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2006;(2) CD003327. [PubMed]
2. Tinoco R, Tinoco A, El-Kadre L, Peres L, Sueth D, et al. Laparoscopic common bile duct exploration. Ann Surg. 2008;247:674–9. [PubMed]
3. Williams EJ, Green J, Beckingham I, Parks R, Martin D, Lombard M. Guidelines on the management of common bile duct stones (CBDS) Gut. 2008;57:1004–21. [PubMed]

Articles from Annals of The Royal College of Surgeons of England are provided here courtesy of The Royal College of Surgeons of England