Laparoscopic Reverse Cholangiopancreatography (LRCP)

Background: Laparoscopic common bile duct exploration (LCBDE) is safe and efficacious. “Classic” LCBDE technique utilizes isolated choledochoscope-guided retrograde basketing; however, it is less effective than transcholedochal exploration. We report on the evolution of our LCBDE technique away from “classic” transcystic approach towards prioritizing antegrade clearance using a novel algorithm utilizing a variety of tools, which we term laparoscopic reverse cholangiopancreatography (LRCP). Methods: We report an algorithm-driven LRCP technique for LCBDE that tailors intervention to the patient’s anatomy and stone burden (size, location, number) seen on cholangiogram (IOC). For cystic ducts ≥4 mm, we use a choledochoscope-assisted technique versus a fluoroscopy-guided technique if <4 mm. For small stones, we use wire basketing (with the “classic” technique) or the “snow-plow” maneuver. For medium (≤10 mm) or multiple stones, we utilize sphincteroplasty plus “snow-plow” if needed. For large (>10 mm), we use laser or electrohydraulic lithotripsy. Fallback methods are ERCP or transcholedochal exploration. Results: We retrospectively reviewed our 80 LCBDE cases at a single Veterans Affairs hospital: 50 cases in the “classic” phase and 30 subsequent cases using LRCP. Transcystic clearance was significantly higher for LRCP at 97% vs. 56% during the “classic” phase (χ2=15.14, P <0.001). There was zero utilization of choledochotomy during LRCP. Conclusions: Algorithm-driven LRCP dramatically improved transcystic clearance success and reduced reliance on choledochotomy. Our algorithm serves as a decision aid, allowing surgeons to utilize a variety of available tools for LCBDE.