Laparoscopic Choledocotomy for Common Bile Duct Exploration

Video Type: CVideo
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Author: Manish Parikh
Published:
Specialties: General Surgery
Schools:
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Basic Info

Contributor: Manish Parikh

The patient is a 50 year-old man with a history of gallstone pancreatitis treated with endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct stent at an outside hospital. The patient subsequently had migration of the stent into the stomach and recurrent choledocholithiasis. This is a video demonstrating techniques used for laparoscopic common bile duct (CBD) exploration via choledochotomy with primary closure of the duct. The intraoperative cholangiogram revealed the “meniscus sign” consistent with a large stone at the ampulla.  

Attempts at transcystic CBD exploration failed due to a tortuous duct and inability to pass the fogarty balloon. A laparoscopic choledochotomy was then made for stone extraction.  A longitudinal choledochotomy was performed sharply after exposing the anterior aspect of the common bile duct.  Intraoperative choledochoscopy confirmed the stone at the ampulla.  A 4Fr fogarty catheter was used to extract the stone.  Repeat choledochoscopy confirmed clearance of the duct.  The choledochotomy was closed with 4-0 PDS  sutures in interrupted fashion. The patient’s stent was removed from the stomach via intra-operative Esophagogastroduodenoscopy (EGD) at the conclusion of the procedure.

If the surgeon confirms that the common duct is cleared, the evidence supports primary closure of the duct.  In scenarios where the duct is not completely cleared of stones or if there is doubt, closure over a 14-16Fr t-tube is performed.

A 10 Fr. JP is routinely left in the right upper quadrant when a choledochotomy is performed. 

DOI: http://dx.doi.org/10.17797/hawlc80i6c

Editor Recruited By: H. Leon Pachter, MD

Advanced

Procedure

Laparoscopic cholecystectomy, intra-operative cholangiogram, choledochotomy with common bile duct exploration, choledochoscopy

Indications

Choledocholithiasis

Contraindications

Surgeon-dependent

Instrumentation

Setup

Supine with operator and one assistant on patient¢s left side, second assistant on patient¢s right side

Preoperative Workup

Laboratory assessment including liver function tests, right upper quadrant ultrasound

Anatomy and Landmarks

Laparoscopic dissection of Calot¢s triangle was performed in the standard fashion with the fundus of the gallbladder retracted over the dome of the liver and the infundibulum retracted laterally. A cholangiogram was performed via a cystic ductotomy. This demonstrated a large filling defect in the CBD. A transcystic CBD exploration was attempted, however fogarty balloon catheters were unable to be passed due to the tortuosity of the cystic duct.

Therefore, a choledochotomy was performed after exposing the anterior aspect of the common bile duct. Choledochoscopy was performed to visualize the stone in the CBD. 4Fr Fogarty balloon was passed through the choledochotomy and used to extract the stone. Repeat choledochoscopy was performed to verify clearance of the CBD. Since the CBD was demonstrated to be completely cleared, the CBD was closed primarily with interrupted 4-0 PDS sutures. If unsure regarding complete clearance of the CBD, we close the choledochotomy over a 14-16Fr t-tube. A completion transcystic cholangiogram was performed to ensure no leakage from the choledochotomy closure site. A 10 Fr JP was placed in the right upper quadrant, which we do routinely after common bile duct exploration. Completion of the cholecystectomy was then performed in the standard fashion.

Advantages/Disadvantages

Complications/Risks

Bile leak from cystic duct stump or choledocotomy
Common bile duct stricture
Biloma
RUQ abscess

Disclosure of Conflicts

Acknowledgements

References

1.Martin I L, Bailey I S, O¢Rourke R, Nathanson L, Fielding G. Towards t-tube free laparoscopic bile duct exploration a methodologic evolution during 300 consecutive procedures. Annals of Surgery, 1998; 228: 29-34.
2.Gurusamy KS, Koti R, Davidson BR. T-tube drainage versus primary closure after laparoscopic common bile duct exploration: review. The Cochrane Library, 2013; 6: 1-39.

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