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Objective: With the advent of the Laparoscopic Cholecystectomy (LC) era, the loss of tactile element hindered the detection of cystic duct stones (CDS) during surgery. These stones are implicated in the post cholecystectomy pain syndrome, failure of the insertion of intra-oprative cholangiogram (IOC) catheter and the subsequent development of common bile duct (CBD) stones. The preoperative imaging rarely detects their presence. The aim of this analysis is to quantify the frequency of the incidental finding of CDS during LC and to emphasise the importance of the awareness of it in our routine practise.

Method: A cohort of consecutive patients undergoing LC during the period from November 2006 to May 2010 were included. Data was collected prospectively. Their liver function tests were documented in the preoperative period. The procedure entailed careful dissection of the cystic duct to the proximity of common bile duct. A clip was then placed at the gall bladder and cystic duct junction. If an IOC was required, the cystic duct was opened in the routine fashion. A partially closed endoclip was then used to milk the cystic duct towards the gallbladder; any CDS encountered were retrieved and documented. If IOC was not indicated, the cystic duct was milked prior to the application of gallbladder/cystic clip.

Results: The study included 330 patients; 80 male and 250 females. Age ranged between 16 to 88 years (Median 50, IQR: 36,62). In 266 patients no CDS were detected. However, in 64 (19%) patients CDS were identified using the above technique; 28 (45%) having a single stone. The remaining 36 (55%) patients had more than one stone with a maximum detected number of 7 stones in the cystic duct. Preoperative imaging failed to detect CDS in the majority of cases. Of those 64 patients with CDS, 47 (75%) showed deranged liver function tests at some stage of their disease prior to surgery. In comparison, of the 266 patients with no CDS, 152 (57%) also demonstrated abnormal liver function tests.

Discussion: The results demonstrate the fact pre-operative investigations are not helpful in diagnosing cystic duct stones. Their occurrence is common. In order to detect CDS, specific intra-operative vigilance is needed. Careful upward milking of the cystic duct before applying clips is a simple, safe and effective way of detecting and extracting these stones. This study changed our practice as this procedure is now included in all our Laparoscopic Cholecystectomies.