Choledocholithotomy is a surgical procedure designed to remove stones that have migrated into the common bile duct. This duct transports bile, a digestive fluid produced by the liver, from the liver and gallbladder into the small intestine. The intervention involves making an incision into the duct to clear the blockage. The primary goal is to restore the flow of bile and prevent complications arising from obstruction.
When Choledocholithotomy Is Indicated
The surgery is indicated for choledocholithiasis, a condition where gallstones move from the gallbladder and become lodged in the common bile duct. This blockage prevents bile from reaching the intestine, leading to a buildup that requires intervention when stones are too large or impacted for less invasive removal.
Symptoms often include jaundice, a yellowing of the skin and eyes caused by bilirubin accumulation. Patients may also experience severe, persistent pain in the upper right abdomen. A serious indication is acute cholangitis, a bacterial infection of the bile duct system presenting with fever, jaundice, and severe abdominal pain.
Choledocholithotomy focuses solely on clearing the common bile duct. It is often performed alongside a cholecystectomy if the gallbladder is still present and is the source of the stones. Treating the ductal stones is a priority, especially when the blockage has led to infection or pancreatitis.
Methods of Performing the Surgery
Choledocholithotomy is accomplished through several methods, depending on the stone’s size, location, and the patient’s condition. The most common approach is a minimally invasive technique, often performed laparoscopically. This involves making several small abdominal incisions for specialized instruments and a camera.
The surgeon performs a laparoscopic common bile duct exploration (LCBDE), accessing the duct through the cystic duct stump or via a small incision called a choledochotomy. A flexible choledochoscope is passed into the duct to visualize the stones and guide their removal using specialized baskets or graspers. After clearance, the incision may be closed with sutures or left open over a temporary drain.
If stones are large, numerous, or the patient has complex anatomy, a traditional open choledocholithotomy may be necessary. This technique requires a larger single incision in the upper abdomen, providing direct visibility and manual access. Open surgery is reserved for situations where less invasive methods have failed or are not feasible, such as when the common bile duct is significantly dilated.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
ERCP is an endoscopic procedure often used before or with surgery. A flexible tube is passed through the mouth, stomach, and into the small intestine to access the bile duct opening. This technique allows a gastroenterologist to perform an endoscopic sphincterotomy—a cut to widen the duct opening—and then retrieve the stones using a balloon or basket. ERCP is often the initial treatment, and surgery is pursued if it is unsuccessful, such as with deeply impacted or very large stones.
Immediate Post-Procedure Management
The first 24 to 72 hours following the procedure are spent in the hospital, focusing on pain management and monitoring the stability of the biliary system. Patients receive intravenous pain medication, transitioning to oral medication as they stabilize. Monitoring vital signs and checking for signs of infection, such as fever, are standard during this early recovery phase.
A temporary drainage system, often a T-tube, may be placed in the common bile duct, especially after an open procedure or if significant inflammation was present. This T-shaped tube drains excess bile externally into a collection bag. The T-tube ensures a low-pressure environment, aiding the ductal incision healing, and it also allows for a post-operative X-ray (cholangiogram) to check for residual stones.
The T-tube remains in place for one to six weeks until the surgeon confirms the bile duct is healing and bile is flowing properly into the small intestine. Before discharge, patients are instructed on drain site and collection bag care. Discharge occurs when pain is controlled with oral medication, the patient tolerates liquids and soft foods, and vital signs are stable.
Home Recovery and Return to Activity
Home recovery requires careful attention to incisional care and a gradual return to normal life. Incision sites, whether small laparoscopic punctures or a larger open incision, must be kept clean and dry according to the surgeon’s instructions. Patients should monitor the sites for increasing redness, swelling, or persistent drainage, which could indicate a developing infection.
Dietary adjustments often involve a temporary shift to low-fat foods. Since the bile duct has been manipulated and possibly the gallbladder removed, the digestive system needs time to adjust to the constant flow of bile into the small intestine. A low-fat diet helps minimize the digestive burden and reduce symptoms like diarrhea and bloating.
Light activity, such as walking, is encouraged immediately to aid circulation and prevent complications. Patients must avoid heavy lifting or strenuous exercise for four to six weeks to allow the abdominal wall and internal surgical sites to heal completely. A full return to work and regular activity ranges from two to six weeks, depending on the surgery type and job demands.
Patients must be aware of specific warning signs requiring immediate medical attention. These include:
- A persistent high fever above 101.5°F.
- The return of jaundice.
- Severe abdominal pain not relieved by prescribed medication.
- A significant change in the color or volume of drainage from a T-tube site.