Nassar Ahmad H M, Hayyawi Israa, Khan Khurram S, Attia Abdelaziz, Omran Asmaa
Laparoscopic Biliary Service, University Hospital Monklands, Airdrie, Lanarkshire, Scotland, UK.
Golden Jubilee National Hospital, Glasgow, Scotland, UK.
Surg Endosc. 2025 Feb;39(2):1341-1350. doi: 10.1007/s00464-024-11477-4. Epub 2025 Jan 6.
Stone impaction is an obstacle to successful laparoscopic common bile duct exploration (LCBDE). This study aims to identify the incidence, operative difficulties and techniques used to disimpact and remove impacted stones during LCBDE.
Prospectively collected data from a large series of LCBDE. Preoperative and operative findings in patients with impacted stones including the difficulty grading, impaction site, disimpaction methods, operative complications and postoperative outcomes were analysed.
136 of 1447 (9.4%) LCBDEs had impacted stones; 63.2% females, median age 54 years. 88.2% were emergencies including 94 Jaundice (69.1%), 19 acute pains, 6 acute cholecystitis and 5 pancreatitis. 16.9% had previous ERCP, all at other units pre-referral. LCBDE was transcystic in 52 (38.2%) and via choledochotomy in 84 (61.8%), all requiring choledochoscopy. LCBDE was difficulty grade IV in 60 (44.1%) and grade V in 76 (55.9%). The number of stones ranged from 1 to 70 (median 2) and stone size 4-30 mm (median 11). Impaction was at lower CBD in 83 (61%), Mid-CBD 29 (21.3%), Intra-hepatic 15 (11%), intra and extra hepatic in 6 (4.4%) and intramural in 3. Disimpaction was by biopsy forceps fragmentation in 37 patients (27.2%), basket dislodgment in 35 (25.7%), biopsy forceps plus basket/hook retractor or cholecochoscope push in 20 (14.7%), Fogarty/Foley balloon with or without basket in 15 (11%), laser in 12 (8.8%), grasper fragmentation in 9 patients (6.6%), and open conversion in 7 (5.1%); 3 stone removal, 2 choledochoduodenostomy and 2 hepaticojejunostomy. Stones left for postoperative ERCP in four patients (2.8%). The median operative time was 160 min.
Impacted stones increase the difficulty of LCBDE. The evolution of techniques and instruments over the course of this study increased the success of transcystic exploration and reduced reliance on choledochotomy. The prediction of impaction, availability of lithotripsy and increasing experience should improve postoperative outcomes.
结石嵌顿是成功进行腹腔镜胆总管探查术（LCBDE）的一个障碍。本研究旨在确定LCBDE期间嵌顿结石的发生率、手术难度以及用于解除嵌顿和取出结石的技术。
前瞻性收集一系列LCBDE的资料。分析嵌顿结石患者的术前和术中发现，包括难度分级、嵌顿部位、解除嵌顿方法、手术并发症和术后结果。
1447例LCBDE中有136例（9.4%）存在嵌顿结石；女性占63.2%，中位年龄54岁。88.2%为急诊病例，包括94例黄疸（69.1%）、19例急性疼痛、6例急性胆囊炎和5例胰腺炎。16.9%的患者既往接受过内镜逆行胰胆管造影术（ERCP），均在转诊前于其他单位进行。52例（38.2%）通过胆囊管进行LCBDE，84例（61.8%）通过胆总管切开术进行，均需要胆总管镜检查。60例（44.1%）的LCBDE手术难度为IV级，76例（55.9%）为V级。结石数量为1至70个（中位值2个），结石大小为4至30毫米（中位值11毫米）。83例（61%）结石嵌顿于胆总管下段，29例（21.3%）嵌顿于胆总管中段，15例（11%）嵌顿于肝内，6例（4.4%）肝内外均有嵌顿，3例嵌顿于壁内。37例患者（27.2%）通过活检钳破碎解除嵌顿，35例（25.7%）通过网篮脱位，20例（14.7%）通过活检钳加网篮/钩形牵开器或胆道镜推挤，15例（11%）通过Fogarty/Foley球囊（带或不带网篮），12例（8.8%）通过激光，9例患者（6.6%）通过抓钳破碎，7例（5.1%）转为开放手术；3例进行了结石取出术，2例进行了胆总管十二指肠吻合术，2例进行了肝管空肠吻合术。4例患者（2.8%）的结石留待术后行ERCP取出。中位手术时间为160分钟。
嵌顿结石增加了LCBDE的难度。在本研究过程中，技术和器械的发展提高了经胆囊管探查的成功率，并减少了对胆总管切开术的依赖。对嵌顿的预测、碎石设备的可用性以及经验的增加应可改善术后结果。
