Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis

Background: A single-stage minimally invasive procedure would be optimal for management of cholecysto-choledocholithiasis. Two alternative strategies are available: management by laparoscopy alone or a combined laparoscopic-endoscopic approach. This study evaluates the results of the latter procedure. Methods: From June 1993 to September 1997, 1400 patients with symptomatic biliary stone disease were evaluated for laparoscopic cholecystectomy. Intraoperative cholangiography was performed on the basis of a preoperative suspicion of bile duct stones; bile duct stone treatment was by intraoperative endoscopic retrograde sphincterotomy. Results: Intraoperative cholangiography was performed because of a preoperative suspicion of a bile duct abnormality in 141 of 1400 patients (10%) undergoing laparoscopic cholecystectomy because of biliary stone disease. Of those 141 patients, 54 (38.3%) presented with pathologic findings (bile duct stone [52] and papillary stenosis [2]); all 54 underwent intraoperative endoscopic sphincterotomy. Complete clearance of the ductal stones was achieved in 43 patients (82.7%) by intraoperative sphincterotomy, and in 9 patients by an additional postoperative endoscopic procedure. Laparoscopic cholecystectomy was carried out in all cases. There were no conversions to an open operation. Postoperative course in the uncomplicated cases was comparable to that for laparoscopic cholecystectomy alone. The postoperative complication rate was 5.6% and mortality 1.8%. Mean hospital stay was 3.3 days (range 2 to 16). At a mean 38 months follow-up, no complications related to the laparoscopic-endoscopic procedure were observed. Conclusion: The intraoperative combined laparoscopic-endoscopic approach seems to be a feasible and effective management of cholecysto-choledocholithiasis, saving patients a subsequent invasive procedure.