10-15% of people suffering from choledocholithiasis develop stones in the common bile duct (the central bile vessel through which all of the bile drains from the liver to the duodenum and the intestine (figure).
The stones of the common bile duct usually migrate from the gall bladder and remain there, but they can also form in the common bile duct (primary bile duct stones). A result of choledocholithiasis is the obstruction of the common biliary duct that clinically presents as jaundice (yellow pigment of the conjunctiva of the eyes), dark-colored urine, feces discoloration, as well as an increase of bilirubin values in laboratory testing. Moreover, occlusion may cause cholestasis and germ growth resulting in the occurrence of inflammation (acute cholangitis) manifesting with pain, fever, jaundice, even hypotension or drop of the level of consciousness. Moreover, gallstones are a predisposing factor for lithiasic pancreatitis. MRCP (Magnetic Resonance CholangioPancreatography) is very important in the diagnosis of choledocholithiasis and biliary diseases.
Treatment choices for choledocholithiasis include endoscopic removal of gallstones at a dedicated GI clinic as well as surgery. ERCP- Endoscopic Retrogade CholangioPancreatography is the method of choice. It is usually performed preoperatively and is followed by laparoscopic cholocystectomy. Alternatively, it may be performed postoperatively if the presence of gall stones is not detected during surgery or if the patient develops jaundice.
Laparoscopic exploration of the common bile duct is a safer therapeutic approach for choledocholithiasis. Many authors argue that a cholangiography should be performed intraoperatively during any cholecystectomy, while others support that it should be performed on suspected choledocholithiasis only.
The technique includes dissection of the cystic duct and removal of the gall stones with a special balloon catheter. Alternatively, an incision may be made directly on the common bile duct (choledochotomy), removal of gallstones, its suturing and placement of a T-tube drain that will be removed postoperatively.
This procedure is now performed laparoscopically with good results (80-95%), lower morbidity as compared to open surgery (3-15%), while hospitalization lasts 4-5 days. This procedure may be performed concurrently with cholecystectomy or in case of failure of ERCP.