Recommended Performance Standards for Laparoscopic Bile Duct Exploration
LCBDE as a procedure is within the remit of all UK consultant Upper GI surgeons with adequate training and experience
As LCBDE training/competence is not currently defined, providers of LCBDE should have attended accreditation course and mentorship as part of good medical practice, unless mentored by a consultant colleague or the surgeon has completed as training as part of a fellowship in a high-volume unit (>25/year)
Annual audit of outcomes
If a LCBDE service is available within your hospital, patients should be made aware that laparoscopic bile duct exploration with cholecystectomy is an alternative treatment to 2 stage treatment laparoscopic cholecystectomy + ERCP
Those patients who have had previous cholecystectomy should have ERCP as the primary treatment option for new presentation of CBD stones
CBD stones refractory to extraction by ERCP/Spyglass - If LCBDE is not available locally, arrangements should be made for referral of suitable surgical patients to a nearby unit that does, rather than treatment with repeated biliary stents
Trans-Cystic exploration should be considered as the primary approach (less morbidity) if size of stones and anatomy allow
Natural history of small CBD stones is unclear- acceptable to treat if clinical indication, presence of deranged liver function tests/pancreatitis/cholangitis
Bile Duct diameter for choledochotomy should be ≥10mm to limit risk of bile duct stenosis, ≥8mm in a high volume/experienced LCBDE surgeon’s hands
Choledochotomy should be performed vertically using sharp dissection (not diathermy)
Bile ducts should be closed primarily and a T tube applied only for a specific indication (defined- unable to clear duct/inflamed bile duct wall/treatment of complication/morbid patient)
KPIs
Conversion rates <10%
Duct clearance rates > 85% (aim for > 90%)
Bile Leak Rates < 5% (defined as a leak of bile requiring intervention-additional procedure)
Returns to theatre < 5%
Readmission rates after elective and emergency cholecystectomy with LCBDE within 30 days <15%
Overall Morbidity < 15%
Overall Mortality < 1%