Laparoscopic CBD exploration

DR.MATHISEKARAN.T

INTRODUCTION
Laparoscopic cholecystectomy became the standard approach for removal of the gallbladder, traditional common bile duct exploration has become an infrequent procedure. Techniques have been shown to be both safe and effective. The long-term sequelae of sphincterotomy also can be avoided with laparoscopic bile duct clearance

The Transcystic Approach to Choledocholithiasis

Primary aproach via cystic duct avoid incision in CBD.
Current transcystic management of bile duct stones requires competence in intraoperative cholangiography. Cholangiogram performed under fluoroscopy adds minimal time to the procedure
-identifies the small percentage of unsuspected bile duct stones -defines ductal anatomy

After minimally invasive access to the abdominal cavity is achieved, laparoscopic ports are placed in a standard fashion for laparoscopic cholecystectomy

A-laparoscope B and C- gall bladder retraction D- working port E- cholangiogram catheter

Following dissection of the gallbladder neck and identification of the cystic duct, a surgical clip is placed on the cystic duct at the level of the gallbladder.

A small cystic duct incision is fashioned just below the clip and its lumen is Identified.

 A 5-Fr cholangiogram catheter is inserted percutaneously in a location that will facilitate further access to the cystic duct and common bile duct the catheter is flushed with saline to clear it of air. A dissector is used to advance the catheter into the ductotomy and is then secured with a non-occlusive surgical clip.

A Normal cholangiogram demonstrating all pertinent anatomy B Abnormal cholangiogram C Ultrasound demonstrating common bile duct stones (arrows).

A normal cholangiogram will demonstrate the entire bile duct without filling defects. Unobstructed flow should be demonstrated into the duodenum, through the cystic duct/common bile duct junction and through the bifurcation of the hepatic duct with filling of the intrahepatic biliary radicals. If a normal cholangiogram is observed, the catheter can be removed, the cystic duct may be ligated,and the gallbladder can be removed in the usual fashion. If stones are found in the common bile duct or hepatic ducts, a decision can be made then on how to proceed.

For common bile duct stones less than 3 to 4 mm in diameter, an attempt should be made to mechanically flush the stones from the duct. Intravenous administration of 1.0mg of glucagon can help relax the sphincter of Oddi and facilitate passage of small stones.

Four minutes following glucagon administration the cystic duct catheter is flushed with several 10-mL syringes of saline

A repeat cholangiogram should be performed. If the duct is clear, the cholecystectomy can then be completed in the usual fashion. If small gallstones (3 mm or less) remain in the duct but flow is demonstrated into the duodenum observation and expectant management.

Clearing of CBD

For common bile duct stones that are too large to be cleared by simple flushingremove these stones with a Fogarty balloon catheter. A 4-Fr Fogarty is inserted with graspers transcystically into the common bile duct past the stones. The balloon is then inflated, and the catheter is slowly withdrawn from the cystic duct with the graspers. the Fogarty will carry the stones out of the cystic duct and into the abdomen repeat cholangiogram gallbladder can be removed

Fogarty balloon catheter

Dormia stone retrieval basket

Laparoscopic Transcystic Choledochoscopy

Effective for the removal of bile duct stones in the majority of cases. A laparoscopic choledochoscope or ureteroscope with a 1.2-mm working channel allows the removal of stones under direct vision.

Additional Laparoscopic Equipment Needed

Flexible choledochoscope or ureteroscope with 1.2-mm working channel Laparoscopic padded graspers for manipulation of choledochoscope Second camera and light source for choledochoscope or ureteroscope Second video monitor or picture within a picture switch Pressurized saline connection for working port of choledochoscope

Additional Laparoscopic Equipment Needed

5-French cholangiogram or ureteral catheter 0.035-inch flexible-tipped hydrophilic guide wire 5-French angioplasty catheter with 8-mm balloon or urethral dilators 12-French abdominal wall introducer sheath Wire retrieval baskets

Dilation of the cystic duct with an angioplasty balloon catheter.

Dilating the cystic duct with an angioplasty balloon can facilitate retrieval of stones and passage of the choledochoscope through the cystic duct. An 8-mm angioplasty balloon catheter is placed over the guide wire into the cystic duct.
Inflated to 6 atm of pressure for 5 minutes. The balloon is then deflated and the catheter is removed.

The catheter is then removed, in a Seldinger fashion, leaving the guide wire in place. With the guide wire in place, a plastic sheath approximately 12 Fr in diameter is placed over the wire through the abdominal wall. Allows safe passage of the choledochoscope and other equipment into the abdomen without injuring

a 3-mm inner cannula, of the type commonly used to pass an endoscopic ligation loop, can also be used through a standard laparoscopic port to pass the choledochoscope.

cannula will prevent injury of the scope by the ports valve and may be less expensive than other sheaths.

Seldinger technique

The Seldinger technique is used in combination with a rigid scope with a working channel. A soft filiform wire or a thick suture is inserted through the channel. The scope is withdrawn and a ventricular catheter is slid down the wire. The remainder of the shunt is inserted in the usual fashion.

Once visualized in the abdomen, the scope can be advanced into the cystic duct with graspers,which are padded to protect the flexible scope. A separate camera, light source, and monitor are then used to observe the interior of the ducts. Adequate visualization of the duct interior requires that pressurized saline is connected to a working side port of the choledochoscope A water-tight valve is needed on the end of the working port to prevent the spray of saline while guide wires and baskets are used in the scope

Once a stone is encountered, the guide wire is removed and a wire retrieval basket is inserted through the working port. Underdirect vision, the stone is grasped within the basket and the stone is pulled back against the end of the scope. The retrieval basket, scope, and stone are removed from the common bile duct and then the cystic duct as one unit. The stone is then released in the abdomen in a convenient location where it can be found later for removal with the gallbladder

Troubleshooting
Inability to advance the scope through the cystic duct
tortuous and long, multiple valves pass the angioplasty balloon or urethral dilators and dilate the duct given sufficient time to dilate Examine the original cholangiogram and dissect the cystic duct toward the common bile duct junction. There will typically be a section of cystic duct near the common duct which is more straight and direct. Second ductotomy can be created in the cystic duct more distally. leave enough cystic duct to safely ligate the duct at the completion of the procedure

Solution

Troubleshooting Stone that is impacted in the ampulla

Solutions
stones can frequently be advanced through the ampulla into the duodenum gentle pressure on the stone with the tip of the scope until the duodenum is visualized. CAREFULincrease the risk of postoperative stricture and pancreatitis

Troubleshooting Stones found in the hepatic ducts

Solutions dissection of the cystic duct can be performed safely to the level of the common bile duct, allowing a near 90 angle between these ducts. The head of the choledochoscope should be angled proximally once in the common bile duct, and the scope should be directed toward the hepatic ducts can enable passage of the choledochoscope into the proximal system and removal of stones

Direct Laparoscopic Choledochotomy

very distal insertion of the cystic duct into the common bile duct very small cystic duct numerous stones (>5),stones that are too large to be brought out through the cystic duct stones located in the proximal hepatic ducts

Endoscopic stone removal

Endoscopic stone removal For ducts less than 8 mm in diameter significant overlying inflammation.

Laparoscopic choledochotomy large common bile ducts that are easily visualized. when endoscopic stone removal is not practical or is impossible secondary to patient anatomy ( prior antrectomy).

Following cholangiography, the anterior common bile duct is identified near its junction with the cystic duct. The cystic duct is ligated

An endoscopic ligating loop should be used for large cystic ducts. The tissue overlying the common bile duct is cleared bluntly or with assistance of ultrasonic dissection.

Electrocautery is to be avoided to prevent injury to the common bile duct. The initial ductotomy is made with small, sharp scissors. The incision is extended just far enough to allow removal of the stones and T-tube insertion.

Once the choledochotomy is created, the stones are removed with graspers or a Fogarty balloon

The choledochoscope can then be inserted to inspect the proximal and distal ducts directly in order to confirm clearance of the duct system. Any additional calculi that are identified can be removed with retrieval baskets

Once the duct is visually clear, a 10- to 14-Fr T-tube is cut to shape as in an open exploration. The T-tube is inserted into the ductotomy with graspers. The ductotomy is then closed around the T-tube with 4-0 absorbable sutures.

Intracorporeal suturing and knot tying will reduce trauma to the edges of the choledochotomy. The end of the T-tube is pulled through a lateral port site, and a completion cholangiogram is taken

Several authors have described improved outcomes following primary closure of the common bile duct without a T-tube. Following closure of the common bile duct, the gallbladder is dissected from the hepatic bed. The gallbladder and all previously extracted gallstones are placed in a laparoscopic retrieval sac and removed from the abdomen. A closed suction drain is placed in the hepatic bed and the laparoscopic ports are removed.

Postoperative Care
If a T-tube was placed, adequate time is allowed for tract formation to occur about the T-tube. Generally, 10 to 14 days is sufficient. A T-tube cholangiogram is taken before removal of the tube. Any retained stones may be removed via theT-tube sinus tract via the flexible choledochoscope (Burhenne technique).

Postoperative Care
For transcystic exploration with secure duct ligation and a normal postoperative cholangiogram,no supplementary care is required. If the sphincter of Oddi was assessed and transgressed by the choledochoscope,a postoperative serum amylase is reasonable given the small but definable incidence of pancreatitis.

Dr.H.Joachim Burhenne
A former professor of radiology in San Francisco . A native of Hannover, Germany, and a graduate of Maximilian Medical School in Munich Dr. Burhenne escaped from the German army into Switzerland in the closing days of World War II. He came to the United States in 1954 and moved to San Francisco in 1959. In 1974, he developed the Burhenne Technique for removing gallstones through bile ducts. In 1984, after developing a radiologic prostate procedure, Dr. Burhenne remained awake and supervised while a colleague performed the

Complications
The most common biliary complications include avulsion or perforation of the cystic duct, which are
usually detected intraoperatively with a completion cholangiogram.

Other complications persistent cholangitis, pancreatitis, retained stones often can be avoided with proper patient selection and technique. Most mortality is secondary to co-morbid cardiac and pulmonary disease.

Results
Laparoscopic choledochotomy is highly effective at stone clearance. Most series report greater than a 90% clearance rate.

The complication rate is higher than transcystic exploration.

A morbidity range of 5% to 18% is reported, with a similar mortality rate to that of transcystic exploration.

Conclusion

Laparoscopic common bile duct exploration does require additional operating room time and equipment, but it should be within the grasp of most laparoscopic surgeons. Patients benefit include fewer invasive procedures, lower morbidity, and an intact sphincter of Oddi at the completion of therapy

Laparoscopic common bile duct exploration has been demonstrated to be a safe and effective alternative to endoscopic therapy. Surgeons who perform laparoscopic cholecystectomy perform Transcystic duct exploration as well.