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%