Laparoskopische Exploration des Hauptgallengangs (Ductus choledochus)

Background: Debate and controversy remain concerning detection and management of common bile duct (CBD) stones in the era of laparoscopic cholecystectomy (LC). Since ERCP was introduced in the 1970s, therapeutic splitting with endoscopic sphincterotomy (ES) as a two-step procedure has become the most accepted strategy to remove CBD stones. This paper evaluates the one-step laparoscopic management of CBD stones during LC. Methods: After economic clarification (anamnesis, clinical examination, laboratory tests, ultrasound) LC was performed even when CBD stones were suspected. During LC a cholangiography via the cystic duct was routinely performed. If bile duct stones were detected during cholangiography, retrieval via the cystic duct or via choledochotomy was intended using Dormia basket or Fogarty catheter. Exclusion criteria against laparoscopic CBD exploration were suspicion of malignancy, severe pancreatitis and/or cholangitis or unfitness for general anesthesia. Results: From November 1991 to September 2005, 260 patients underwent laparoscopic therapy for bile duct stones. Retrieval was performed transcystically in 166 patients (64%) and via choledochotomy in 94 patients (36%). Laparoscopic CBD exploration was successful in 93%. Conversion rate, complication rate and mortality were 1.5% (n = 4), 6.6% (n = 17), and 1.1% (n = 3), respectively. Conclusions: Laparoscopic common bile duct exploration (LCBDE) as a one-step procedure is a safe alternative to therapeutic splitting, with comparable success rate. Regarding morbidity and mortality, the laparoscopic transcystic approach has clear advantages over therapeutic splitting. In more than 90 per cent of patients with CBD stones, LCBDE avoids diagnostic and therapeutic ERCP and preserves the papilla Vateri.