SAGES 2001 Hands-On Course II

1. The Rationale to Perform Intraoperative Cholangiography
and To Explore the Common Bile Duct During Laparoscopic Cholecystectomy

1. The Rationale to Perform Intraoperative Cholangiography and To Explore the Common Bile Duct During Laparoscopic Cholecystectomy

L. William Traverso, M.D.

Clinical Professor of Surgery, University of Washington

Staff Surgeon, Virginia Mason Medical Center

1100 Ninth Avenue (C6-Surg), Seattle, Washington 98111

There are seven reasons to perform intraoperative cholangiography and laparoscopic common bile duct exploration. First I would like to pose a question that begins with this statement - "Before intraoperative cholangiography was developed, the indications to explore the common bile duct were - palpable common bile duct stone; multiple small stones in the gall bladder; history of jaundice, pancreatitis or cholangitis; and a dilated or thickened common bile duct." These indications for the exploration of the common bile duct were routinely used before the advent of routine intraoperative cholangiography (IOC). These were common Board questions. However, these criteria resulted in 72% of the cases having a negative common bile duct exploration. The Ohio State group first showed this unacceptably high number in 1972. (1) The authors showed these criteria to explore the CBD were relatively non-specific and that new criteria needed to be developed.

This data suggests a more modern question. What is the incidence of common bile duct stones when IOC is performed routinely? Our group found the incidence to be 10% (2) in 1994, but it is not a new figure. It has been shown regularly that about 10% of patients when examined routinely by IOC at the time of surgery will have stones in the common bile duct.

A surgeon has five choices during cholecystectomy if common bile duct stones are found. The first of the five choices is to avoid that information, do not do an IOC, then the surgeon will not be perplexed by what to do with that information. Or the surgeon could choose to observe the patient clinically and just see what happens to the common bile duct stone. The remaining choices involve something a surgeon likes to do - action. The choices are open common bile duct exploration; send the patient for a postoperative ERCP, an endoscopic papillotomy, and removal of the stone in the immediate postoperative period; or a laparoscopic common bile duct exploration, a technique that is easily learned without having to attend costly courses. That is why you are taking this course. First one must perform IOC to have the problem of deciding what to do about the CBD stone.

That leads me to another question - If a common bile duct stone is intentionally left in the common bile duct, will something bad happen? The answer to that question is "unknown" because it has never been adequately studied. Currently there is an ongoing prospective, randomized, NIH-sponsored trial to answer this question. I believe the stone will cause trouble for some patients and should be treated. I'd rather not leave the interested surgeon without objective data to make a rational decision to look for CBD stones during surgery and then treat them. The following data from our institution shows that common bile duct stones DO CAUSE PROBLEMS. Just after laparoscopic cholecystectomy began in the early 1990's, we looked at 78 patients that had been transferred to our medical center for problems with post-laparoscopic cholecystectomy pain. We found that 2/3 of the patients had common bile duct stone-related problems; a very small percentage of them had a normal post-laparoscopic cholecystectomy ERCP; and about a quarter of them had iatrogenic problems, which included common bile duct injuries or cystic duct leaks. Looking at just the gallstone-related problems, we found that about half of the gallstone-related problems were due to retained common bile duct stones and the other half were due to post-laparoscopic cholecystectomy pancreatitis or papillary stenosis. (3) Clearly, in our tertiary referral center, we were seeing gallstone-related problems after laparoscopic cholecystectomy from stones remaining in the CBD!

This fact leads me to the first reason why IOC should be done and CBDE then accomplished intraoperatively. You should want to explore the common bile duct at the time of "lap chole" if common bile duct stones are present. Why? Reason Number One - because you believe that common bile duct stones can cause trouble and should be addressed around the time of laparoscopic cholecystectomy.

Lets go on to reason number two which states that IOC should be performed routinely and not selectively. Of course, the best way to avoid dealing with common bile duct stones is to avoid their discovery and not to perform intraoperative cholangiography. In fact, surgeons felt so uncomfortable with handling common bile duct stone in this new era of laparoscopic cholecystectomy, that many patients had routine preoperative ERCP. One study in Germany by Neuhaus showed that routine preoperative ERCP discovered bile duct stones in 11% of patients before laparoscopic cholecystectomy. This incidence does not come as a surprise. As we have discussed, routine IOC has shown about a 10% incidence of stones. It is not a surprise that routine preoperative ERCP would also find that same percentage of patients having stones in those contemplating cholecystectomy. Using "selective" criteria, mainly related to liver function tests, Larson and colleagues performed preoperative ERCP in only those patients meeting those selective criteria before laparoscopic cholecystectomy. They increased their discovery of common bile duct stones to 33%. Clearly, 2/3 of the patients undergoing selective preoperative ERCP with all of its inherent risks did not benefit. Usually we do not perform preoperative ERCP, even on a selective basis, but rather do routine IOC and handle just the patients with common duct stones.

This discussion begs to ask the following question. The presence of a stone in a common bile duct just before or during laparoscopic cholecystectomy is best predicted by which one of the following - any abnormal liver function tests; an ultrasound showing a common bile duct stone; a history of passing a bile duct stone (that is acholic stools, jaundice, or dark urine); or any combination of the previous three? We found that the presence of a common bile duct stone is not predicted well by any of these answers. In that study an elevation of any liver function test was only associated with a 30% chance of seeing a common bile duct stone. If the ultrasound predicted a common bile duct stone, only 28% of those patients had a stone. In fact, the best predictor of the presence of a stone was a simple history of passing a common bile duct stone. In those few patients with that history, 45% had common bile duct stones. However, this history was present in very few patients and, therefore, was not helpful in almost all of the patients. When we combined any of the above, our detection rate went to only 27%. (4)

To answer the question "What test best predicts the presence of a stone in the common bile duct?" we concluded that "There are no predictive tests that can sufficiently increase an observer's probability estimate of the presence or absence of common bile duct stones to allow the surgeon to make selective decisions on whether to offer selective preoperative ERCP or selective IOC."

Now, I would like to add Reason Number Two to do routine IOC and CBDE -----Reason Number 1 was common bile duct stones cause trouble. Reason Number Two is that routine IOC is important because criteria to allow for adequate selection of patients on whom to selectively perform intraoperative cholangiography are not known.

We learned a number of lessons during laparoscopic cholecystectomy in the early 1990's. We learned that more bile duct injuries were being seen and new criteria for prevention and recognition had to be relearned or learned and then implemented. We learned the role for IOC was most important during routine application because there were no adequate selection criteria. We also learned, as will be emphasized in subsequent discussion, that IOC had to be interpreted by the surgeon on a real time basis using a pre-established checklists to avoid bile duct injury and also to avoid missing common bile duct stones. The third lesson we learned in regard to common bile duct stones was that we had laparoscopic CBDE in addition to pre- and postoperative ERCP, but this new technique had to be justified by long-term follow-up.

If the surgeon sees a stone during laparoscopic cholecystectomy, what should be done? Basically, when stones are discovered intraoperatively, there are one of four decisions to make. Helpful to this discussion is information gained from a study we published where we followed 55 patients after positive IOC. Our intraoperative choices for these patients were open common bile duct exploration; send the patient for postoperative ERCP; do a laparoscopic transcystic common bile exploration; or observe clinically (if the cholangiographer felt that the observed defect was an artifact or a tiny stone). Note that the surgeon must make this determination, not the radiologist. Also note there are several reasons why ERCP might not be the right choice - your community may not have ERCP available, the success rate may be so low that you might not wish to not rely on ERCP to remove a stone that you find during IOC, or the endoscopist may not want to do it. I posed the following question to our four therapeutic endoscopists "With which patients would you not wish to attempt post-laparoscopic cholecystectomy ERCP to retrieve a common bile duct stone or, in other words, in which cases is a surgeon obligated to treat the discovered stone at the time of surgery?" Since the long-term follow-up for young patients after endoscopic papillotomy has not been performed, they did not wish to perform an endoscopic papillotomy in a patient less than 40 years of age and wished for me to try laparoscopic common bile duct exploration. They also did not want to see faceted stones greater than 2 centimeters in diameter. These stones are very difficult to remove and they wanted those removed at the time of a probable open common bile duct exploration. A third category was the presence of a common bile duct stricture with multiple intrahepatic stones. These required many hours of endoscopic fluoroscopy time and could probably be removed best by open common bile duct exploration. If there was a common bile duct stricture, these required treatment of the stricture as well and ruling out the presence of a neoplasm. A partial caveat is the presence of a Roux-Y or Billroth II gastrectomy at the time of laparoscopic cholecystectomy. Obviously many of these cases have to be done open. The stones could be handled during the open procedure without need to rely on post-open cholecystectomy ERCP. Many of these cases can be done laparoscopically and, if faced with this situation during laparoscopic cholecystectomy, it is possible that a surgeon would be contemplating post-laparoscopic cholecystectomy ERCP in one of these two types of patients with Roux-Y or Billroth II reconstructions. A qualified endoscopist can handle almost every patient with a Billroth II reconstruction, but only about 50-75% can be handled if they have Roux-Y reconstruction. The surgeon must make this decision in this uncommon situation.

Reason Number Three to explore the common bile duct and to perform routine IOC is that with some common bile duct stones, no one wants to help the surgeon. Reason Number Four is when the expertise may not be available in your area. There may not be therapeutic endoscopists in your medical community or, if there are, they may not provide you with a satisfactory success rate to avoid a post-laparoscopic cholecystectomy, post-aborted ERCP, open common bile duct exploration.

It is my intent to show how the IOC can provide a quicker decision to decide on laparoscopic common bile duct exploration, open common bile duct exploration, or post-"lap chole" ERCP. There are items on the cholangiogram that can predict the success rate of laparoscopic common bile duct exploration. These items will help to avoid excessive OR time if laparoscopic common bile duct exploration will have a low success rate as predicted by the intraoperative cholangiogram. Rapid decision-making not only decreases potential morbidity but also saves operating time. All of these more precise decisions will decrease expenses.

Consider the following question - What is the most limiting factor for successful laparoscopic common bile duct exploration: 1) low insertion of the cystic duct; 2) multiple stones; or 3) no one knows where the equipment is when I need it? The answer to this question is number 2 - multiple stones, because as we showed in 1995 (5) multiple stones are associated only with a 35% success rate, while, if single stones are present, there is an 87% success rate. This success rate used flushing and basket techniques only. Choledochoscopy was not utilized. The expense and the cumbersome set-up of the flexible choledochoscope, usually in an after-hours situation, were avoided in this study, as simple techniques designed to be utilized through the medium of intraoperative fluoroscopic imaging allowed these techniques to become very useful and inexpensive, plus no special courses are required.

This begs the question -"What percent of patients when found to have common bile duct stones during IOC will have multiple stones? This, of course, is very important since the success rate with multiple stones is lower and one might wish to go to an open common bile duct exploration or to rely on postoperative ERCP with multiple stones, as long as they are not multifaceted and greater than two centimeters or above the stricture. We found multiple stones to be present in 60%. (5) What are other potential causes of failure? Proximal stones cannot be reached with transcystic techniques unless the stones can be moved distally by moving the patient on the operative table. Remember that some stones are heavier than bile and sink and other stones are lighter than bile and float. Optimization of the table angle will help to reach these stones. Anomalous cystic ducts can have some obstacles to access to the main common bile duct, particularly the low insertion or the left sided duct, which is circuitous to circumvent with wires or baskets or even with a choledochoscope. The low inserting cystic duct is present in only two percent of the cases and left-sided ducts are seen in only 12% of the cases. (2)

Taking all of these factors into account, the surgeon will be successful in the majority of cases, as we found in our own institution at the very beginning of our learning curve. (5) However, we have developed our expertise so that our current success rates have climbed by 15-20%. I suggest you monitor yours. The outcome summary for common bile duct stones discovered during laparoscopic cholecystectomy at our institution at the beginning of the learning curve shows that simple transcystic techniques avoid ERCP in over half the cases and the results of success persist with a follow-up at 1.8 years after laparoscopic cholecystectomy. (5) The surgeon wishing to do these techniques must realize that intraoperative fluoroscopy is mandatory, but wire basket technology is already available either through your interventional radiologist or your urologist. These techniques can be brought into the operating room and employed to simplify treatment, provide less risk to the patient, and to save money. Laparoscopic common bile duct exploration is currently evolving, with new technology all the time.

Let's discuss this money issue from an objective rather than an emotional basis. How much does laparoscopic common bile duct exploration cost and how much is this cost in comparison to ERCP or open common bile duct exploration? Our calculations were made on actual cases using relative value units, professional charges, and facility charges. (6) After these calculations were completed all charges were made relative to a patient just undergoing laparoscopic cholecystectomy with IOC where no additional treatments were necessary. Therefore, just a patient having a laparoscopic cholecystectomy with a negative IOC and then going home after the day following surgery was arbitrarily equated to one hundred percent, or 1X if you will. If the patient underwent laparoscopic cholecystectomy, had a positive IOC, and then went on to a postoperative ERCP the next day, those charges were 190% of the patient that just had the laparoscopic cholecystectomy with negative IOC. If the IOC was positive, how much extra would a successful laparoscopic common bile duct exploration cost with the extra equipment, the extra OR time, and with the patient still able to go home on the next day? The answer is 14% with laparoscopic CBDE versus the cost going up 90% with postoperative ERCP. Of interest is that if a laparoscopic common bile duct exploration was attempted, but was unsuccessful and the patient went on to an ERCP, then the charges would be only 7% higher than if the laparoscopic common bile duct exploration had not been performed. Clearly, if the surgeon is successful with laparoscopic common bile duct exploration, significant savings can be provided for the medical care system. If the surgeon is not successful, very little additional charge is incurred as that patient goes on to an ERCP.

Reason Number Five is now added to our list of reasons to do IOC and CBDE -laparoscopic common bile duct exploration that was indicated by IOC saves money. I said there were seven reasons to perform IOC and Lap CBDE. What are the other two reasons? I believe that it is a matter of professional pride for the surgeon to take the common bile duct problems back into our purview with new technology. New technology, if applied in an economically sound basis, will save money as has been illustrated. It will also decrease exposure of the patient to the obligate risks of post-laparoscopic cholecystectomy ERCP.

I would like to expand the list of why to perform intraoperative cholangiography to these seven reasons.

1. Common bile duct stones cause trouble. We repetitively see this in patients referred to us who have not had routine intraoperative cholangiograms.

2. Routine intraoperative cholangiograms are important because there are no selective criteria that can adequately predict the presence of common bile duct stones. Therefore, these cholangiograms must be performed intraoperatively on a routine basis.

3. There are cases where no one wants to help the surgeon and it is our responsibility to solve the problem.

4. There may not be expertise in your area to allow your patient to have postoperative ERCP in a safe and efficient manner.

5. Laparoscopic common bile duct exploration saves money and, even if it fails, it does not add to the cost of post-laparoscopic ERCP stone retrieval.

6. The purview of common bile duct stone treatment has traditionally been the general surgeon's. With new technology, we can now retrieve choledocholithiasis in an economically feasible fashion.

7. Finally, the seventh reason to do intraoperative cholangiography is one that you have already thought of during this discussion and I have left it out intentionally.

As you add your item to my six reasons, remember that new surgical procedures will survive if they provide "surgical value package." That package is best described as providing a service that has reasonable outcomes for a reasonable price. As these items are benchmarked and monitored, either in the short-term or the long-term follow-up basis, quality will increase driving costs down.

References

1. Kakos GS, Tompkins RK, Turnipseed W, Zollinger RM. Operative cholangiography during routine cholecystectomy. Arch Surg 1972;104:484-488.

2. Traverso LW, Hauptmann EM, Lynge DC. Routine intraoperative cholangiography and its contribution to the selective cholangiographer. Am J Surg 1994;167:464-468.

3. Traverso LW, Kozarek RA, Ball TJ, et al. Endoscopic retrograde cholangiography after laparoscopic cholecystectomy. Am J Surg 1993;165:581-586.

4. Koo K, Traverso LW. Do preoperative indicators predict the presence of common bile duct stones during laparoscopic cholecystectomy? Am J Surg 1996;171:495-499.

5. Rousch TS, Traverso LW. Management and long-term follow-up of patients with positive cholangiograms during laparoscopic cholecystectomy. Am J Surg 1995;169:484-487.

6. Traverso LW. A cost-effective approach to the treatment of common bile duct stones with surgical versus endoscopic techniques. In Berci G and Cuschieri A, eds, Bile ducts and bile duct stones. W.B.Saunders Co., Philadelphia, 1997, 9 154-160.

2. Laparoscopic Interoperative Cholangiography

Douglas O. Olsen, M.D.,F.A.C.S.

Associate Clinical Professor of Surg.

Vanderbilt University

Dept. of Surgery, Baptist Hospital

Nashville, TN.

Approximately 15% of all patients who suffer from cholelithiasis will have concomitant choledocholithiasis.1 Although some of these patients will present with signs and symptoms of their choledocolithiaisis, approximately 5% of the common bile duct stones will be asymptomatic at the time of the patients presentation.2,3,4 Of those patients who do present with signs or symptoms of choledocolithiaisis, the diagnosis is at best tentative, since no one sign or symptom is pathognomonic for the disease. The only pre-operative study that will give definitive evidence of the absence or presence of common bile duct stones is a cholangiogram, either obtained retrograde using the technique of ERCP (endoscopic retrograde cholangiopancreatography), or percutaneously with PTC (percutaneous transhepatic cholangiogram). Both of these studies have morbidity and cost associated with the performance of the tests, precluding them from being used routinely as screening procedures. As a result, the surgeon performing cholecystectomy must have a technique to evaluate the common bile duct interoperatively. Interoperative cholangiography is the tool best suited for this evaluation. The technique was originally described in 1932 by Mirizzi,5 and has been used by surgeons performing cholecystectomy ever since. Although ultrasound has received a lot of attention in recent years as an alternative to cholangiography, it is far more user dependent and the ability of the surgeon to evaluate the biliary system for either anatomy or the presence of injury can be limiting. Cholangiography is still considered the gold standard for this purpose. With the introduction of laparoscopic cholecystectomy, the surgeon was faced with new technical challenges due to the limitations imposed by the laparoscopic approach. Not only was the surgeon forced to operate in a two dimensional environment, but he lost the ability to palpate the common bile duct. These factors increase the importance of cholangiography as a tool for the identification and evaluation of the patients biliary tree during the performance of a laparoscopic cholecystectomy. Most surgeons would agree that cholangiography does play an integral role in the operative management of gallbladder disease, and is therefore a technique that every biliary tract surgeon needs to be able to perform easily and efficiently.

INDICATIONS

Although most surgeons would agree that cholangiography plays some role in the performance of a laparoscopic cholecystectomy, there is an ongoing debate as to the indications for the procedure.2-4,7-11 There are proponents for the routine use of cholangiography, arguing that the information obtained with the study outweighs the additional cost and time required to perform the procedure. On the other side, are advocates for the selective approach. The question of routine vs. selective cholangiography has been debated ever since cholangiography was first described by Mirizzi in 1932. With the popularization of laparoscopic cholecystectomy, the same debate was carried through to laparoscopic cholecystectomy.12-17 Many of the same arguments for routine cholangiography during standard open cholecystectomy are being used to argue routine cholangiography during laparoscopic cholecystectomy. Although these arguments are valid for laparoscopic cholecystectomy, there are unique characteristics of the laparoscopic cholecystectomy that make routine cholangiography even more important to consider.

One very important and basic difference is that the laparoscopic procedure is a visual operation with little to no tactile sense to help the surgeon during his dissection. The surgeon needs to draw upon every tool at his disposal to enhance his ability to identify the anatomy and carry out a safe dissection. The cholangiogram gives the surgeon that "road map" that allows him to identify the relationship between the cystic duct, common duct, and the hepatic radicals. This not only allows him to carry out a safe dissection, but positively identifies the anatomy to help prevent "major" transection injuries to the ductal anatomy. An important characteristic of the laparoscopic technique is the intense upward traction that is applied to the gallbladder during the dissection. This increases the risk of the common duct being mistaken for the cystic duct and inadvertently being divided if the anatomy is not clearly defined. In a review of 130 cases of laparoscopic cholecystectomy in which a bile duct injury occurred, 74% of the injuries were of the "major" transection type.18 Interoperative cholangiograms were performed in only 22% of the cases in which a major transection occurred. In each case, the cholangiogram demonstrated the impending danger of a possible transection, but the surgeon ignored the findings! Although the cholangiogram can prevent a transection, it is argued that the cholangiogram itself creates a ductal injury. This is true, but the injury is minimal compared to the injury that occurs if no cholangiogram is performed. In one series, in which routine cholangiography was performed, the incidence of bile duct injury was no lower than that of other series. But none of the injuries where major transections, and all the injuries were recognized immediately and repaired successfully without a biliary enteric anastomosis.14 This was in comparison with a series in which selective cholangiography was practiced, demonstrating greater that an 80% incidence of injuries requiring biliary enteric anastomosis for repair. Furthermore, in cases in which cholangiography is not performed, the injury is typically not recognized.19 This increases the risk of a poor outcome when the injury is identified and ultimately repaired.

A second important characteristic of laparoscopic surgery is the difficulty in controlling bleeding in delicate locations. The cholangiogram allows the surgeon to perform his initial dissection high on the neck of the gallbladder where the anatomy is "obvious" and safe. The more proximal anatomy can then be identified and "mapped" utilizing cholangiography. This technique avoids excessive dissection down near the common duct. This will minimize not only problems with bleeding in an area that can be difficult to control, but also potential tearing injuries that can occur when the surgeon works at clearing the cystic duct/common duct junction.

The issue of clarifying the question of incidental common duct stones cannot be overemphasized. Most series quote approximately a 5% incidence of incidental common bile duct stones.4-6 By definition, these stones are found in patients with no indications of common duct problems preoperatively. This makes up 1/3 of all common duct stones. It is true that as many as 80-90% of these incidental stone will eventually pass on there own, but a finite number of these will remain only to cause symptoms at a later time.4,7-10 A portion of these patients will first present with a major complication of choledocholithiasis. Routine cholangiography gives the surgeon a chance to identify these patients in the asymptomatic state when the treatment is both easier and less morbid that when they present acutely. In addition, identifying these patients at the time of the laparoscopic procedure allows the surgeon to attempt treatment with cystic duct choledochoscopy.20 If successful with the choledochoscopy, the patient is saved the need for post operative ERCP.

Finally, there is the issue of cost and time. It is estimated that one high duct transection will cost in the range of $330,000 to treat.14 Avoiding just one of these duct transections will pay for all the "routine" cholangiograms that a surgeon will perform in his career. With the use of fluoroscopic cholangiography, the operative time is increased by a mere 5-10 minutes, a small price to pay to avoid a major duct transection.

If we select to follow the argument for selective cholangiography, there are both absolute indications and relative indications for the performance of interoperative cholangiography. Absolute indications would include signs or symptoms of common bile duct stones (TABLE 1), evidence of a ductal injury, or inability to clearly demonstrate the anatomical landmarks with dissection. A relative indication would be the presence of acute cholecystitis.21,22 These indications are independent of the issue of routine vs. a selective approach. The argument for selective cholangiography is based to a large degree on the issue of cost effectiveness. This, combined with the additional time and skill required to perform a cholangiogram, makes the argument of "selective cholangiography" very attractive. One of the biggest problems with a selective approach, is that the surgeon often does not use, or ignores, the clinical criteria for performing cholangiography and performs too few cholangiograms. When performing selective cholangiography using just the indication of possible common bile duct stone, the surgeon should be performing cholangiograms in at least 10% to 15% of his patients. This number correlates with the incidence of symptomatic common bile duct stones. As the patients age increases, so does the incidence of common bile duct stones and likewise the number of cholangiograms that should be performed using a selective approach.(TABLE 2) If you then consider the cases of uncertain anatomy and acute cholecystitis, it is easy to see how the number of "selective" cholangiograms grows to 30%-40% of patients undergoing cholecystectomy.

TECHNIQUE

GALLBLADDER CHOLANGIOGRAPHY

Interoperative cholangiography has been described utilizing one of two basic approaches. The simplest and most direct approach is to perform the cholangiogram directly through the gallbladder.23 After insertion of a needle into the fundus of the gallbladder, the bile is aspirated, and the gallbladder is then filled with approximately 30cc of contrast. Either plain film radiography or fluoroscopy will yield images of the biliary system. Drawbacks of this technique include the inability to easily control the amount of contrast infusion, and the limitations of obtaining an adequate study if there is cystic duct obstruction. Gallbladder cholangiography may not be possible in as many as 20%-30% of cases because of cystic duct occlusion.21(acute cholecystitis and hydrops of the gallbladder) Without the ability to control the infusion of contrast, poor filling of the upper radicals can be a problem. Furthermore, the cholangiogram is performed before any dissection of the cystic duct has occurred, limiting the ability of this technique to aid in the identification and verification of the ductal anatomy.

CYSTIC DUCT CHOLANGIOGRAPHY

The most versatile of techniques is cystic duct cholangiography. Because the study is performed through the cystic duct, it is useful even with cystic duct obstruction. Since the dissection of the cystic duct has already been completed when the procedure is performed, the cholangiogram serves as an objective study not only demonstrating the positive identification of the anatomy, but the lack of any ductal injury.

The technique of cystic duct cholangiography begins with isolation of a length of cystic duct high on the neck of the gallbladder. Actual mobilization of the infundibulum and neck of the gallbladder is a must to minimize the problem with inadvertent cannulization of the common bile duct. The serosal attachments of the neck of the gallbladder are first released laterally. This avoids unnecessary dissection in the triangle of Calot until some of the basic landmarks are clearly identified. To further mobilize the neck, the medial serosal attachments are released taking care to avoid injury of the cystic artery as it courses along the neck of the gallbladder. Only the thin serosal attachments are divided, avoiding the inadvertent injury to any of the ductal structures if the dissection has been initiated in the wrong location. If there is a question about a cystic duct being markedly shortened, the cholangiogram should be shot through the gallbladder itself. It is important to stress the need to completely mobilize the neck of the gallbladder in a continuous circumferential manner to avoid the possibility of missing a right hepatic or common hepatic duct passing posteriorly.24 With the infundibulum and the neck of the gallbladder completely mobilized, a clip is placed across the neck to prevent any stones from passing down into the cystic duct with further manipulation of the tissues. Prior to placing the clip, the cystic duct is milked back towards the gallbladder to clear any small stones that might lie in the cystic duct. If the cystic duct is particularly short, the clip can be omitted to allow the cholangiocatheter to be placed as high on the cystic duct as possible. Traction and exposure is maintained on the gallbladder with one grasper on the fundus, and one on Hartman's pouch.

With the cystic duct exposed, a catheter is passed through a needle sheath as a separate puncture, a "fifth" access site. Since this is made with a 14 gauge needle, the trauma to the patient is minimal. The needle is placed in such a way that the catheter will be entering the abdominal cavity along the same axis as the cystic duct, facilitating passage of the catheter down the cystic duct. With the catheter passed through the needle sheath into the abdominal cavity, a scissors is introduced into the abdominal cavity through the epigastric trocar and used to make a small incision in the cystic duct. Once again, the cystic duct is isolated high on the neck of the gall bladder to eliminate the chance of mistaking the common duct for the cystic duct. A grasper is used to direct the tip of the catheter into the cystic duct incision and advance the catheter down the duct. The catheter is secured with a clip, taking care not to overcrimp the clip. This is accomplished by having the assistant inject saline through the catheter as the clip is closed. The crimp on the clip is halted just as resistance to flow is felt. Although static cholangiographic films can be obtained, there is true advantage to utilizing fluoroscopy. Digital fluoroscopy yields high quality films with the advantage of a dynamic study. Since identification of the ductal anatomy is one of the advantages of cholangiography, it is important to attempt to fill the common hepatic duct along with the hepatic radicals with the injection. A fluoroscopic exam make this an easy task, allowing the surgeon to adjust the force of the injection to assure complete filling. Once the exam is complete, the clip is easily removed by grasping the hub of the clip and pulling backwards. Once the clip and catheter have been removed, the laparoscopic cholecystectomy is carried out in the usual fashion. An alternative to the percutaneous technique is to use a cholangiogram clamp. This allows the surgeon to introduce the catheter and secure the catheter with a single instrument inserted through the lateral trocar.

A number of catheters have become available to facilitate laparoscopic cholangiography. The balloon catheter is one which was modified from a vascular irrigation catheter and will often work. Because the balloon catheter relies on the cystic duct to secure the catheter when the balloon is distended, the catheter has its limitations when the catheter can not be fully passed down the duct, or when there is a short cystic duct. Ureteral catheters work well, but because of the side hole the catheter once again has its limitations in that it has to be passed down into the cystic duct far enough to occlude the side hole. The mushroom catheters need only to be wedged into the hole in the cystic duct, and held in place with either the clamp or a clip. With their rigid nature, the available metal catheters are easier to manipulate, but they do not conform easily to the slight variations that often occur with trocar placement or differences seen in the anatomy. This, along with their rigidity, can increase the potential risk of trauma to the cystic duct. With the wide variety of catheters and techniques available, a Surgeon should be able to find a system that works well, allowing a cholangiogram to be performed whenever indicated.

No matter what position a surgeon takes regarding selective vs. routine cholangiography, he must be able to perform a cholangiogram when needed. A surgeon must find a technique that works well for himself and become proficient in it's performance. Even the most selective of cholangiographers should be performing cholangiograms at least a quarter to a third of the time. In selective cholangiography, the surgeon looks for a reason to perform the procedure, and in routine cholangiography the surgeon looks for a reason not to perform the procedure. Routine does not means always, just as selective does not mean never!

TABLE 1
INDICATIONS OF BILE DUCT STONES1

1. Stone in the common duct on ultrasound or roentgenography

2. Obstructive jaundice

3. Dilation of the common duct greater than 1.2 centimeters

4. Previous cholangitis

5. Preoperative pancreatitis

TABLE 2
Incidence of Bile Duct Stones at Cholecystectomy According to Age2

AGE (YEARS)	ALL PATIENTS/ # WITH STONES	PERCENTAGE
10-20	25/4	16
21-30	92/11	12
31-40	226/21	9
41-50	325/28	9
51-60	473/67	14
61-70	275/85	31
71-80	116/56	48
81-90	11/10	96
TOTAL	1543/282	18

BIBLIOGRAPHY

1. Schwartz S, Shires G, Spencer F, Storer E. Gallbladder and extrahepatic biliary system. Principles of Surgery. McGraw-Hill 1984; 4:1307-1343.

2. Rolfsmeyer E , Bubrick M, et el. The value of operative cholangiography. Surg Gynecol Obstet. 1982;154:369-371.

3. Hermann R. Surgery for acute and chronic cholecystitis. Surg Clinics of North America. 1990;70:6:1263-1275

4. Mofti AB, Ahmed I, et el. Routine use of selective peroperative cholangiography. Br. J. Surg. 1986;73:548-550.

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6. Stiegmann G, McIntyre R, Pearlman N. Laparoscopic intracoporeal ultrasound. An alternative to cholangiography? Surg Endosc. 1994; 8(3):167-71.

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9. Nauta R. Selective vs routine use of intraoperative cholangiography. ArchSurg. 1989;124:1041.

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3. Imaging the Biliary System (Ultrasonography): Laparoscopic Ultrasound of the Bile Duct for
Choledocholithiasis

Maurice Arregui, M.D.

Introduction

With advances in ultrasound technology including the refinement of laparoscopic ultrasound probes, ultrasound of the bile duct to identify common bile duct stones is a feasible alternative to intraoperative cholangiograms. The advantages of laparoscopic ultrasound include: no exposure to radiation, it is not dependent on an x-ray technologist, it is faster than cholangiography to perform, and it gives anatomical information on surrounding structures. In this manuscript, we describe the indications, anatomy, technique, findings, limitations and outcomes of laparoscopic ultrasound.

Indications

All patients undergoing laparoscopic cholecystectomy are candidates for laparoscopic ultrasound of the biliary tree. This can be performed on a routine basis or selectively on patients with increased risk factors for choledocholithiasis. These risk factors include acute cholecystitis, elevated liver function tests, hyperamylasemia, or a dilated common bile duct. Additionally, patients with acute or chronic thickening or inflammation around the hepatoduodenal ligament in which the anatomy is obscured will benefit from ultrasound evaluation to help delineate the anatomy. Ultrasound is also useful to confirm the integrity of the common bile duct after ligation of the cystic duct, which would rule out injury of the common hepatic or common bile duct. Additionally, laparoscopic ultrasound is very valuable in the event that gallbladder cancer, cholangiocarcinoma, pancreatic cancer or ampullary tumors are suspected or incidentally found. Under these circumstances, laparoscopic staging with ultrasound provides a more accurate means of evaluating local invasion, vascular involvement, nodal staging, liver metastasis and peritoneal metastasis.

Relative contraindications to laparoscopic ultrasound are: excessive inflammation, pancreatitis, large amount of fat or many adhesions, which would obscure the anatomy or make it difficult to access the head of the pancreas or duodenum.

Anatomy

The gallbladder - The gallbladder is best visualized just under the liver edge between segment four and five of liver. The gallbladder is pear shaped with the fundus extending below the liver edge. Typically the gallbladder has three echo layers. The mucosa is hyperechoic and the muscularis is hypoechoic. The third layer represents the peritoneum or the adventitia surrounding the gallbladder (Figures 1, 9, 10, 11)

Segment four liver and intrahepatic biliary tree - The best view of the common hepatic duct and intrahepatic biliary tree is through segment four of the liver. This is just to the right of the falciform about halfway to the gallbladder (Figure 2a). Through this hepatic window, the confluence of the right and left duct is seen to form the common hepatic duct. Deep to this is the hepatic artery, which is usually seen, in a cross sectional view. Behind this is the portal vein, caudate lobe of the liver and the vena cava. This is the starting point for evaluation of the biliary tree and surrounding structures. (Figure 2b)

Hepatoduodenal ligament - Between the liver hilum and the head of the pancreas lies the hepatoduodenal ligament, which contains hilar lymph nodes, the extrahepatic biliary tree, hepatic and cystic artery, portal vein and periportal lymph nodes and lymphatics. (Fig 3a, 3b, 3c, 3d)

View through head of pancreas - The common bile duct enters the head of the pancreas posteriorly. The cystic duct enters at a variable location and often can be seen entering the common bile duct in the head of the pancreas. Anterior to the pancreas, the antrum, pylorus or duodenal bulb serves as the acoustical window to the head of the pancreas. At the cephalad portion of the pancreas, the pancreaticoduodenal artery can be seen anterior to the common bile duct. As the common bile duct courses through the head of the pancreas, it will deviate to the patient's right as it approaches the ampulla. The pancreatic duct can be easily seen as it joins the common bile duct just before it enters the ampulla. Medial to the head of the pancreas, the portal vein can easily be followed coursing posterior to the pancreatic neck. The pancreatic duct can easily be seen just anterior to the portal vein in the middle of the pancreatic parenchyma. From this point to the ampulla, the pancreatic duct can be followed toward the ampulla. Notably, the texture of the pancreas often changes from a hyperechoic to a slightly hypoechoic consistency just before the confluence of the biliary and pancreatic duct. This hypoechoic area is the dorsal portion of the pancreas. The vena cava can be seen posterior to the pancreatic head. (Figures 4 and 5)

Transduodenal view - as we approach the distal portion of the common bile duct, the ultrasound transmission becomes somewhat obscured in many patients due to the overlying parapancreatic omental fat or simply a fatty pancreas which hinders ultrasound transmission. The duodenum, which is usually fluid filled and relatively devoid of bowel gas, provides an excellent acoustical window at this level allowing a better view of the common bile duct, pancreatic duct and ampulla. The image is obtained by placing the probe lateral to the second portion of the duodenum. This will give a cross sectional view of the common bile duct. The ampulla is seen as a target pattern just lateral to the medial duodenal wall. (Figures 6,7 and 8)

Imaging Protocol

We usually ultrasound the biliary tree after first placing ligatures on the cystic duct. Ultrasound is performed after this so that we can check the integrity of the common bile duct. Since we use a 5 mm port in the right upper quadrant, a 5 mm laparoscopic is inserted through this port to allow the surgeon to see the position of the laparoscopic ultrasound probe. The probe is inserted through the umbilical 10 mm port. Some prefer to ultrasound through a 10 mm epigastric port. Since we use a 5 mm port in the epigastrium, we have chosen to insert the probe through the umbilical port. The only drawback to this approach is that the probe may not be long enough in some patients to reach to the dome of the liver if this is necessary. Rarely will we have difficulty reaching the upper portion of the biliary tree from the umbilical port.

With the probe over segment 5, we first identify the gallbladder. If the gallbladder is thickened, we can look for abnormal mucosal patterns, which may identify a neoplasm. For the most part, this is a brief view, which allows us to see shadowing gallstones, sludge, and cholesterolosis, polyps or thickening from acute inflammation.

To evaluate the proximal biliary tree we first get a transhepatic view of the confluence of the ducts by placing the probe over segment four of the liver and try to align the long axis of the probe with the porta hepatis. The liver serves as an excellent acoustical window. As with a fatty pancreas, a fatty liver may reduce the transmission of the ultrasound and make the image suboptimal. The typical view that we try to get is a longitudinal view of the common hepatic duct, which is usually just below the liver, and then a cross sectional cut of the right hepatic artery which more commonly lies between the common hepatic duct and portal vein. The third structure is the portal vein, which is seen longitudinally. The caudate lobe of the liver is the fourth structure and the vena cava is the fifth structure. (Figure 2b) Once these structures are identified, further inspection of the proximal biliary tree can be carried out. The right hepatic duct is usually in line with the common hepatic duct and the left is seen to take off at almost a 90° angle.

Once we have completed the transhepatic evaluation, we then place the probe between the liver and the anterior surface of the hepatoduodenal window to get a longitudinal view of the structures of the hepatoduodenal ligament. (Figures 3b and 3c) At this point we adjust the depth of the image so that we magnify the closer structures. We also adjust the focus to the near field. We now have the probe on the common hepatic duct. In thin patients with small ducts, this may be difficult to find especially when the duct is very superficial without overlying fat or adventitia. The very near field or surface is difficult for the ultrasound probe to capture. When the common bile duct is difficult to find, the liver can be lifted to directly visualize the hepatoduodenal ligament and the junction with the cystic duct. If there is still difficulty finding the common hepatic or common bile duct, it is best to find the portal vein which is usually easily found and then slowly move the probe laterally with a rotating clockwise/counterclockwise motion until the bile duct is identified. The duct is usually confirmed by following it out distally and proximally verifying its normal anatomical path. If there is any doubt, the non-vascular nature of the common bile duct can be confirmed with Doppler or color Doppler. After identifying the common hepatic duct, the probe is advanced caudad toward the pancreatic head and with clockwise/counterclockwise rotation on the long axis, we search for the cystic duct / common bile duct junction. This is at a variable location and can sometimes be seen entering near the ampulla. The most common location is just above the pancreas. It is sometimes useful to get a transverse view of the portal structures above the level of the pancreas. In this view the common hepatic duct is lateral to the hepatic artery and the portal vein is posterior and a larger structure. This is often called the "Mickey Mouse" view since the common bile duct and hepatic artery form the ears and the portal vein forms the face. (Figure 3d)

As we proceed distally, we continue to the intrapancreatic common bile duct. At about this point the common bile duct and the portal vein deviate from each other with the common bile duct heading laterally toward the second portion of the duodenum. (Figure 3a) To continue to get a longitudinal view, the tip of the ultrasound probe must be angled medially. At this point, the fat overlying the pancreas and sometimes just the sheer bulk of the pancreatic head, especially if it is fatty, will obscure the common bile duct and it becomes necessary to get a transduodenal window which provides better acoustical coupling since it is water rather than fat density. Here, the tip of the ultrasound probe is deflected laterally and downward over the duodenum. This provides a Transduodenal view of the common bile duct and ampulla. The duct is followed from proximally to distally and is seen in cross section. The pancreas proximally is hyper- to isoechoic and as the probe goes more distally, the pancreatic parenchyma in most gets somewhat hypoechoic. Near the level of the ampulla the pancreatic duct can be seen approaching the common bile duct at an almost 90° angle. (Figures 4, 5, 6 and 7) Both ducts can then be seen to enter the ampulla, which often can be seen as a target pattern exiting the medial wall of the duodenum. (Figure 8)

It is sometimes difficult to see the intrapancreatic common bile duct because the duct is small or decompressed. Sometimes it is necessary to place a cholangiocatheter in the cystic duct and infuse saline into the bile duct. This distends the distal duct and provides a fluid interface to give a better image. If the distal duct cannot be seen well, careful inspection for shadowing in the region of the distal duct and ampulla is sought as this may represent a common bile duct stone.

Ultrasound Findings:

Gallbladder pathology: The most common finding is cholelithiasis, but sometimes patients can have small non shadowing stones which may be termed sludge or cholesterolosis. (Figures 1, 9 and 10) This can represent tiny calcium bilirubinate stones in the case of sludge, or adherent soft cholesterol clusters in the case of cholesterolosis. Most of the times when the preoperative ultrasound suggests a gallbladder polyp, one finds an adherent soft cholesterol stone rather than a true polyp which are quite uncommon. In acute cholecystitis, the gallbladder wall can be quite thickened due to inflammation and associated edema. Walls thicker than 4 mm are usually associated with very difficult dissections at laparoscopic cholecystectomy. True neoplasms such as polyps or cancer are rarely encountered. Ultrasound is excellent for identifying intraluminal masses and determining the depth of penetration of the gallbladder wall, identifying suspicious lymph nodes and to evaluate for liver metastasis. (Figure 11)

Choledocholithiasis. The main reason for performing laparoscopic ultrasound during laparoscopic cholecystectomy is to look for common bile duct stones. If the duct is large, there is a higher chance of encountering stones. The duct size is measured with acoustic calipers. Stones are more commonly found in the distal duct. Stones can be of any size ranging from one millimeter to several centimeters. They may be shadowing or non-shadowing as in the case of small soft cholesterol stones. A typical stone will have a hyperechoic surface in the shape of the surface of the stone. Posterior to this is shadowing. (Figures 12 and 13) Small stones in the distal duct are especially hard to find if the pancreas is fatty and the duct is not dilated. A small stone can be lodged in the ampulla. If the distal duct is not readily seen, careful examination of the area of the common bile duct for shadowing is important. If visualization is difficult and a stone is suspected, it is helpful to infuse normal saline through the cystic duct to help outline the stone. If the duct is not dilated, there is no shadowing and there is al low probability of a stone, the chances of missing a significant common bile duct is small and cholangiogram is not necessary to confirm a negative exam. Once a stone is found in the common bile duct, it is important to document the size and number. This is important for therapeutic purposes. If the stone is 2 to 3 mm or less, there is a good chance that this can either be flushed through or will pass on its own. If one chooses to flush the stone through, glucagon should be given just prior to flushing. After the glucagon is given, with a catheter in the cystic duct, saline is slowly infused while the ultrasound probe is over the distal common duct to visualize the stone as it is flushed through. Alternatively, this can be done with real time digital fluorocholangiography while infusing contrast material. Often times, these small stones are not seen with cholangiography because they are flushed through before the contrast material reaches the distal common bile duct. There is a risk of impacting the stone in the ampulla, which may cause pancreatitis so careful, monitoring of the pancreatic duct with either ultrasound or cholangiogram is important. If a stone this small does not flush through, this suggest stenosis and a trans-cystic common bile duct exploration or endoscopic papillotomy may be necessary. Stones between 3 to 6 millimeters in size are amenable to transcystic common bile duct exploration for removal. Larger stones or numerous stones may require choledochotomy or endoscopic papillotomy with extraction either intraoperatively or postoperatively. If the stone is greater than 1.5 centimeters, the ability to remove it with endoscopic retrograde cholangiopancreatography (ERCP) is limited and choledochotomy for stone extraction is recommended.

Sludge in bile duct: There is often a small amount of sludge in the common bile duct that is not seen with cholangiography. This is most likely because on cholangiography these particles are small enough that the contrast obscures the sludge or that it passed with the bile before the contrast reaches the distal duct to detect any filling defects. Unless there is a large amount of sludge, this is usually an incidental finding of no clinical significance. At most the patient should be warned that they might have an episode or two of biliary pain should some of this sludge cause partial obstruction in passing.

Anatomy of the biliary tree and surrounding structures: The hepatic duct, cystic duct junction and distal common bile duct are readily seen with ultrasound. The right hepatic and left hepatic duct can also be seen in most cases and certainly when the ducts are dilated. Anomalous branching patterns such as segment 6 duct off the cystic duct or right hepatic duct are difficult to see due to their small size and can be missed. These patterns are best seen with intraoperative cholangiography. The thickness of the bile duct wall, the configuration of the cystic duct hepatic duct junction is well seen with ultrasound. The surrounding structures such as the hepatic parenchyma, lymph nodes, hepatic artery, replaced hepatic artery, portal vein, pancreas, etc., are much better seen with ultrasound.

Ampullary and pancreatic tumors: Occasionally, a patient will be found to have a dilated bile duct with no stone in the common bile duct. Ultrasound is particularly useful on these occasions since an ampullary tumor; bile duct tumor or pancreatic tumor may be identified and staged at that time. Ultrasound can be used to determine the size and location of the tumor. It will also identify vascular encroachment or encasement, asses regional and distant nodes for metastasis and evaluate the liver for metastasis. Biopsies can be performed with ultrasound guidance.

Pitfalls:

Small ducts: These may be very difficult to find especially in thin individuals with minimal periportal fat. Very superficial structures are poorly seen with ultrasound. It is often helpful to elevate the liver to look directly at the porta hepatis to visualize the location of the common bile duct and place the probe directly on top of it. If there is a question of whether the structure is vascular or biliary, Doppler or color Doppler may be useful. If it remains difficult to find, irrigation of normal saline through the cystic duct will produce distention of the duct and make it easier to identify.

Fatty liver: Fat is a poor conductor of sound waves and occasionally a fatty liver that is also thick makes it difficult to see the intrahepatic bile ducts and makes the transhepatic window suboptimal. When this occurs, it is best to just place the probe over the portal structures.

Fatty pancreas: This is perhaps the biggest problem with intraoperative ultrasound. As in the liver, if the pancreas has excessive fatty consistency or there is much overlying omental fat, transmission of the ultrasound beam is diminished and visualization of the common bile duct is obscured. For this reason it is important to use a transduodenal window which gives a water density ultrasound window. The probe should be placed on the lateral duodenal wall facing medially. If this does not give an adequate view and a stone is suspected, infusion of saline through the cystic duct will distend the duct and enhance its contrast with the surrounding pancreatic parenchyma. Careful search must be made for hyperechoic reflection and any shadowing in the pancreatic head. This could represent a stone. Under these circumstances, if the view is suboptimal, small non-shadowing stones or sludge may be missed. A cholangiogram may be necessary or one can accept that these small stones may be insignificant or if the common bile duct is not dilated and there are no indicators suggesting choledocholithiasis and no shadowing is seen, that most likely there is no stone. We have for the most part taken this approach and have not missed a clinically significant stone in our series.

Para-ampullary duodenal diverticula: This can be misleading. Air in a para-ampullary duodenal diverticulum can create a hyperechoic reflection with posterior shadowing. This appears to be in the pancreatic parenchyma. Care must be taken to follow the duct carefully to check to see if this hyperechoic reflection and shadowing is in or outside of the common bile duct. If it is outside of the common bile duct and extremely hyperechoic, is most likely due to air in a diverticulum

Artifacts: Because of overlying structures such as the hepatic artery, posterior enhancement and shadowing at the lateral edges of the artery when overlying the common bile duct can create artifacts of hyperechoic densities in the common bile duct which suggests sludge or a stone. On must be careful to recognize this possible artifact

Results:

There is definitely a learning curve to performing laparoscopic ultrasound for detecting common bile duct stones. The following table reflects our own experience (Table 1). Initially, when we started performing ultrasound, we also performed digital fluorocholangiography (DFCG) to confirm our findings and to learn the limitations of ultrasound. In our first 140 patients, the sensitivity of detecting common bile duct stones was only 76.5% compared with a 100% sensitivity of DFCG. We learned several techniques and pitfalls, which improved the sensitivity to 100% in our next 78 patients. In our last 142 patients, only one common bile duct stone has been missed with laparoscopic ultrasound, intraoperative cholangiography and postoperative ERCP. This patient remained symptomatic and a second ERCP discovered the stone, which was probably lodged in a diverticulum in the bile duct or ampulla. Currently we use only laparoscopic ultrasound and rarely need DFCG.

Conclusions

With experience, laparoscopic ultrasound is as sensitive, more specific and more rapidly performed than digital fluorocholangiography. During the learning curve, laparoscopic ultrasound findings can be confirmed with DFCG until the surgeon is comfortable with the technique.

References

1. Arregui ME, Surgeon's Guide to Ultrasound. General Surgery & Laparoscopy News, McMahon Publishing Group. December 1997.

2. Arregui ME, Laparoscopic Cholecystectomy: Ultrasound and Doppler. Carol E. H. Scott-Conner for the SAGES manual. Fundamentals of Laparoscopy and GI Endoscopy chapter 13.4 pages 162-166 Springer-Verlag. October 1998.

3. Barteau JA, Castro D, Arregui ME, Tetik C, A comparison of intraoperative ultrasound vs. cholangiography in the evaluation of the common bile duct during laparoscopic cholecystectomy. Surgical Endoscopy 1995;9:490-498.

4. Thompson DM, Tetik C, Arregui ME, Laparoscopic Ultrasound. Problems in General Surgery, Lippincott-Raven Publishers, Philadelphia 1997 Vol. 14 No. 1, pp. 107-116

5. Thompson DM, Arregui ME, Tetik C., Madden MT, Wegener M., A Comparison of Laparoscopic Ultrasound with Digital Fluorocholangiography for Detecting Choledocholithiasis During Laparoscopic Cholecystectomy, Surgical Endoscopy. 12 (7):929-32, 1998 July.

6.Thompson DM, Arregui ME, The Role of Laparoscopic Ultrasound in Cancer Management, Seminars in Surgical Oncology. 15 (3):166-75, 1998 Oct.-Nov.

7. Staren ED, Arregui ME (eds.), Diagnostic And Interventional Ultrasound for Surgeons, 1997, Lippincott, Philadelphia, PA.

8. Wegener ME, Kolachalam RB, Arregui ME, Laparoscopic Intraoperative Ultrasonography. In Operative Strategies in Laparoscopic Surgery Phillips EH, Rosenthal R (eds.). Springer-Verlag, Heidelberg, Germany. 1995; pp39-46

Legends for figures:

Figure 1. Laparoscopic ultrasound of the gallbladder through segments five of the liver. Three layers of the gallbladder wall are seen labeled mucosa (1), muscularis (2) and adventitia (3). A gallstone (GS) can be easily identified with a hyperechoic surface and posterior shadowing.

Figure 2a. View of the laparoscopic ultrasound probe over segment four of the liver. The probe is placed through the umbilical port.

Figure 2b. With the probe over segment four parallel with the porta hepatis, the liver parenchyma is first seen followed by the common bile duct (CBD), hepatic artery (HA), portal vein (PV), caudate lobe and vena cava.

Figure 3a. Drawing of the typical relationships of the biliary tree to the hepatic artery and portal vein at the hepatoduodenal ligament.

Figure 3b. View of the probe placed longitudinally over the hepatoduodenal ligament. The liver is raised to show the position of the probe with the tip high in the hilum.

Figure 3c. Longitudinal view with the probe placement as in figure 3b. Note that the common bile duct (CBD) is very superficial. The hepatic artery (HA) is seen in cross section. The portal vein (PV), caudate lobe (CL) and vena cava (VC) follow.

Figure 3d. "Mickey Mouse" view of the hepatoduodenal ligament with transverse placement of the probe.

Figure 4. Drawing of the transducer over the second portion of the duodenum giving a lateral to medial view. This gives a better acoustical window.

Figure 5. Transduodenal view of the head of the pancreas through the duodenum (DUO). The dorsal pancreas (DP) is hypoechoic relative to the ventral pancreas (VP). The pancreatic duct (PD), common bile duct and vena cava are labeled as well.

Figure 6. Laparoscopic view of the probe transducer over the second portion of the duodenum.

Figure 7. Drawing of the probe placed over the second portion of the duodenum. Note that the tip is deflected to give a transverse view.

Figure 8. Transduodenal view of the ampulla (AMP) projecting into the duodenum (DUO). This is often seen as a target pattern.

Figure 9. Cholesterol polyp projecting from the gallbladder wall seen through segment five of the liver.

Figure 10. Gallbladder with sludge. Three layers of the gallbladder wall are clearly seen. A prominent fold of the gallbladder wall is also seen.

Figure 11. Gallbladder cancer (CA1) seen as an irregular thickened mucosal layer. The hypoechoic muscularis (M) is for the most part intact. There is extension of the cancer (CA 2) outside of the gallbladder involving the adventitial layer but not invading the liver. This was found at laparoscopic evaluation. The patient underwent open cholecystectomy with wedge resection of segment five and portal lymphadenectomy.

Figure 12. Stone in the distal intrapancreatic common bile duct (CBD).

Figure 13. Longitudinal view of a common bile duct stone (CBDS) with shadowing. There is also some non-shadowing sludge adjacent to this.

4. Instrumentation for CBD Exploration

George Berci, M.D.

One of the major factors in open or laparoscopic choledochlithotomy is that the operator should be acquainted with the technique, but should know also the instruments in great detail. Before you start surgery talk to the scrub nurse to be sure that all the needed tools are available and in functioning order. There is nothing more frustrating than to be in the middle of a CBD exploration and have some of the instruments missing or non-functioning.

OR time today is a very important economic factor and the administrative, nursing staff, and surgical members have to be aware that a 5-minute delay in surgery can easily cost the patient's insurance company or the third party $100.00 - $150.00.

There are two major groups of instruments:

a. A x-ray unit, preferably a digitized mobile fluoroscope, which in case of suspected stone, should

be in the room in a parking position (Fig. 1). It has to be clearly understood that CBD stone

removal should not be performed without fluoro cholangiography (for details see the Olson

chapter).

b. There should be two trays available with pre-sterilized instruments including the

choledochoscope. Here too, it is essential that these two trays should be in the room for the

same reason as mentioned above. (Fig. 1)

Instrumentation

Even if there are preoperative signs or symptoms of a possibility to harbor a CBD stone, a cholangiogram has to be obtained to verify the size and the number of the stones and the ductal anatomy. In the overwhelming majority, a cystic duct cholangiogram is made and for this reason, a cholangio grasper that has an attached tube for the cholangio catheter (Fr. 3 ureter catheter with end hole) is needed. There should be IV tubing with extension, and Y-connector, two syringes, one with saline, and another one with contrast media on the table.

In case of a positive cholangiogram, a 0.35-inch (or 0.38-inch) guide wire can be introduced through the indwelling cholangio catheter into the CBD. The cholangio catheter is withdrawn over the guidewire. It is advisable to use Teflon or other coated guidewires with soft tips on both ends.

In many instances, the cystic duct is not dilated therefore, a Fr. 5 dilating catheter with a balloon that can be inflated to a 6-mm width with a 40-mm length, which will dilate the cystic duct to accommodate the passage of the choledochoscope. A Fanwell pressure bag (used for emergency transfusion) with a 1-liter saline bag is required, a sterile IV extension to be connected to the choledochoscope to provide irrigation and clear visibility in the extrahepatic ductal system when the scope is introduced.

If the stone is larger, the operator has to decide to consider a choledochotomy. Turning the choledochoscope around if a transcystic approach is performed and calculi are located in the hepatic duct is very difficult, if not impossible.

Stone crushing maneuvers

There are lasers (Holmium) or electric lithotriptors available. They are expensive and need special care. The quartz fiber laser transmitter (or Fr. 3 litho catheter) is introduced through the scope. This stone-crushing equipment is to be considered first in those hospitals where a large volume of biliary cases are operated upon.

Digitized fluoroscope

This unit is currently available in many OR suites where orthopedic surgery is performed. Therefore, the general surgeons can easily obtain a scheduling time and share the use of the equipment. The important advantages are the immediate visibility and high accuracy. This control unit has a double foot switch with two TV monitors available. One displays the enlarged image of the actual site whereby, in pressing the other foot switch, few frames are stored on the other monitor. With this technique, the entire procedure can be completed in a few minutes and 6-12 stored images observed on the other monitor. If a suspicious lucency is seen, this can be enlarged for better scrutiny and selected frames can be earmarked for permanent prints. The most important accessory tools are:

Fr. 3 balloon catheter with a stylet. This can be introduced through a 5-mm trocar with a reducer through the cystic duct towards the sphincter area, inflated and withdrawn, hoping that it will move some smaller calculi into the incision. This is a very inaccurate technique and is not very much employed during laparoscopy.

There are a variety of baskets available. This was originally inherited from urology (Dormia) which in general has a spiral configuration and 4 or 5 round wires in total diameter of Fr. 3 or 4. A basket can be introduced under fluoroscopy or through the choledochoscope. These wires are small and thin and can be easily damaged by repeated manipulations. I prefer the Segura 3 flat wire basket that can be advanced through the choledochoscope and opened with its spring action. Even after repeated attempts, it maintains its configuration (Cook Co.). The fluoroscopic guidance of basketing requires continuous radiation and is less accurate than being done under direct visual control (choledochoscope). In case of fluoroscopy, there should be a leaded screen available in the OR which can be moved in a proper position. The assistant and the nurse should take position behind the surgeon during the actual injection. If this is placed 5-6 feet from the fluoro source, the radiation is minimal. However, it is essential that the OR personnel should be protected. The anesthesiologist should wear a lead apron. If the surgeon wishes to employ the basket under fluoroscopic control, he must have a lead apron and as well, a thyroid shield is recommended.

The choledochoscope

The intraluminal visualization is the most accurate and successful stone removal technique. The stone can be precisely visualized; the introduced basket can be well seen (for details see chapter by Petelin). It is essential that a well-trained team should work with coordinated movements or manipulations. The stone can be easily entrapped in the basket and delivered through the dilated cystic duct.

In the open cholecystectomy era, we introduced the rigid "Hopkins Rod lens" choledochoscope in 1972. We changed later to the flexible one for easier manipulation. The attachment of a television camera became obvious because we were able to observe an enlarged image with the magnified anatomy. The position of the basket relative to the stone can be seen from an optimal distance with both eyes, instead of looking through a small monocular eyepiece. As mentioned above four hands are needed and the use of television technique made it possible to have coordinated movements by the assistant. Simultaneous videotape records can be obtained.

There are a variety of flexible choledochoscopes available. We first started with a larger flexible scope (3.7-mm urethroscope with a channel). We changed to a smaller one working mainly through the cystic duct, and ended up with a flexible scope of 2.8-mm OD with a 1.2-mm instrument channel. It should be noted that a reducer is required from 5-mm to 3-mm as a standard accessory, if you are using the 5-mm trocar as an entrance. We can also select the midline approach with a special catheter (see chapter by Petelin). An additional advantage is to have an integrated small camera built into the handle of the choledochoscope (Fig. 2). In case of laparoscopy, this has the advantage that we do not have to detach the camera from the laparoscope (which is time-consuming if the camera is bagged) and reattach to the choledochoscope and vice versa.

A padded grasper is recommended if you wish to advance the scope on certain occasions to avoid damage to these delicate instruments.

This video choledochoscope with the Micro Video Module (MVM) has other advantages as well. In looking through a fiberscope, you see the moiré or raster of the fiber structure (which can be disturbing during delicate manipulations). This system has electronically eliminated this appearance and a smooth image makes the recognition of the basket vs. the stone easier.

It is important that these instruments for CBD exploration should be properly maintained and kept in an earmarked place to be available on the spot.

These instruments are expensive but they will last longer with appropriate handling and maintenance. The capital outlay is worth the investment, taking into consideration that stones can be removed in one session instead of two procedures (ERCP or ES) or even a re-exploration. A well-trained team is required to perform this procedure well and in time.

Joseph B. Petelin, M.D., F.A.C.S.

Clinical Associate Professor; Department of Surgery

University of Kansas School of Medicine, Kansas City

Director: Surgix--Center for Image-based Surgery & Surgix Laparoscopic Fellowship

Introduction

For the surgeon, the advent of laparoscopic cholecystectomy brought with it not only the challenge of adapting to image-based surgery, ie. videolaparoscopy, but also the challenge of upholding the standard of care which had developed during the one hundred years since the first open cholecystectomy by Langenbuch in 1882. [1-3] Not only is the biliary tract surgeon of this era expected to perform laparoscopic cholecystectmy with the same low morbidity, mortality, and efficacy as in open surgery, but now, he also has an obligation to manage all stone-related biliary tract disease as efficiently, or more efficiently than in the past. [4-13] This responsibility includes surgical management of choledocholithiasis in the least invasive manner possible.

Laparoscopic choledocholithotomy may be performed in a variety of ways. The spectrum of minimally invasive treatment options for common bile duct stones itself ranges from lesser to more invasive techniques. [14-22]

The transcystic approach to choledocholithotomy respresents the least invasive laparoscopic method of managing this problem. As such, it represents a goal which should be sought in any case where it is feasible, safe, and efficient. With such an approach, the patient not only avoids laparotomy, or post-operative ERCP +/- sphincterotomy, but also avoids the morbidity of choledochotomy. In general, with all other factors being equal, these patients are able to be discharged from the hospital and resume their previous life style in the same time period as those patients undergoing uncomplicated laparoscopic cholecystectomy.

The obvious questions that evolve from this position include:

1. Who are the appropriate candidates for a transcystic approach?

2. What are the contraindications to a transcystic approach?

3. What equipment is needed?

4. What are the techniques that are most successful?

5. What is the likelihood of success for this approach?

6. What are the potential disadvantages of this approach?

7. What are the potential complications of this approach?

8. What are the results of this approach?

These and others will be addressed in this treatise. In order to provide the background and rationale for employing a transcystic approach to common duct exploration, an overview of patient management, equipment considerations, cholangiography, and preparation of the Triangle of Calot is necessary.

Patient Management

Pre-operative

The pre-operative treatment of the patient of the patient with choledocholithiasis is often not significantly different than that of a patient with symptomatic cholelithiasis and has been elsewhere discussed. The indications for, and the use of analgesics and antiobiotics as needed, is generally the same as it was in the pre-laparoscopic era. Pre-operative assessment may include sonography, nuclear medicine imaging, computed tomography, hematologic and chemical analysis.

The use of flexible endoscopic intervention, esophagogastroduodenoscopy, (EGD), in these patients should be limited to those in whom the diagnosis of concomitant peptic ulcer disease, upper gastrointestinal or para-alimentary malignancy, or cholangitis is suspected. Flexible upper gastrointestinal endoscopy in the form of endoscopic retrograde cholangiopancreatography, ERCP +/-S, with or without sphincterotomy, may also be required in those patients who are not suitable candidates for a general anesthetic and surgical intervention. It should not be used, however, to routinely "scan" patients suspected of possible common bile duct stones. Nor, should pre-operative ERCP and sphincterotomy be routinely used to remove documented common bile duct stones. [23-28]

Intra-operative

Intra-operative management obviously includes cholangiography and ductal exploration. The surgeon must be facile with at least one method of obtaining intra-operative cholangiograms. He must also be able to decide which method of ductal access (transcystic vs. transductal) is most appropriate, and which technique(s) (balloon, basket, choledochoscopic, etc.) of ductal exploration is/are least invasive and most likely to be successful for the patient.

In many cases, transcystic ductal exploration is possible and highly successful.

Occasionally, however, choledochotomy is necessary or even preferred. Certain characteristics are useful in determining which approach should be employed. They are summarized in the following table. [Table 1]

Factor	Transcystic Approach	Choledochotomy Approach

One Stone	+	+
Multiple Stones	+	+
Stones < 6mm diameter	+	+
Stones > 6mm diameter	-	+
Intra-hepatic stones	-	+
Diameter of Cystic Duct < 4 mm	-	+
Diameter of Cystic Duct > 4 mm	+	+
Diameter of Common Duct < 6 mm	+	-
Diameter of Common Duct > 6 mm	+	+
Cystic Duct Entrance-lateral	+	+
Cystic Duct Entrance-posterior	-	+
Cystic Duct Entrance-distal	-	+
Inflammation-mild	+	+
Inflammation-marked	+	-
Suturing Ability-poor	+	-
Suturing Ability-good	+	+


positive or neutral effect = +
negative effect = -

Table 1. Factors influencing the approach to laparoscopic common duct exploration.

It is evident that some factors don't necessarily influence either approach. Also, it is usually a negative influence precluding the use of a particular method, rather than a positive influence encouraging a specific method, that guides a surgeon to one or the other of the approaches.

An analysis of these factors should be performed by the surgeon for each case of choledocholithiasis. The patient's desire for the safest, most reliable, and least invasive method should be central to the decision-making process.

Equipment

Laparoscopic Cholecystectomy

Basic instrumentation for videolaparoscopy is required for laparoscopic biliary tract surgery. This includes: high flow insufflator, laparoscope, video camera, monitor (s), and mechanical laparoscopic hand instruments such as graspers, scissors. This may be augmented with additional instruments designed to deliver other types of energy such as unipolar electricity, bipolar electricity, laser energy, or ultrasonic energy.

Additionally, for optimum treatment, fluorocholangiographic equipment is a must. This includes not only the fluoroscope and monitors, but also the needles and/or catheters and/or catheter guides necessary to instill contrast material into the ductal system. There are a variety of these systems on the market, and the reader is encouraged to seek that which most easily adapts to his or her local economy and medical-political situation.

Laparoscopic Common Duct Exploration ( LCDE )

In order to perform laparoscopic common duct exploration, additional supplies are needed. All or part of the following list may be required:

1. glucagon, 1 to 2 mg

2. balloon-tipped catheter (s) [4 Fr most commonly, occasionally 3 Fr, 5 Fr]

3. Segura type 4-wire, flat wire basket (s)

4. 0.028" or 0.035" guidewire

5. mechanical "over-the-wire" dilators, [minimum 7 Fr to 12 Fr range]

6. pneumatic "over-the-wire" high pressure dilators

7. IV tubing & normal saline [for installation through the choledochoscope]

8. atraumatic graspers [for choledochoscope control]

9. sterile "dedicated" Mayo stand or cart for duct exploration equipment

10. flexible choledochoscope [ < 3 mm outside diameter preferred; > 3mm usually require

choledochotomy]

11. 2nd light source

12. 2nd camera

13. video switcher/mixer

14. high pressure irrigator (eg. Waterpik TM[Teledyne, Fort Collins, Colorado])

Availability and Set Up

The equipment needed for laparoscopic common duct exploration must be immediately available to the surgeon. Optimally, it should be stored on a separate cart or trolley that is placed in or near the operating theater. The circulating nurse should not have to walk down the hall to search for these instruments in a storage room. (That would be just as inappropriate as not having cardiac medications and devices immediately available on a "code blue"cart on a medical ward.)

Once it is evident that laparoscopic common duct exploration is required, and the surgeon has decided on his preference for equipment, it should be taken from the non-sterile cart and placed on a sterile, preferably separate, cart or Mayo stand by the scrub nurse or her assistant. If the equipment is placed on the same table(s) as the existing laparoscopic cholecystectomy instrumentation, clutter and inefficiency usually result.

The importance of these recommendations cannot be over-estimated, because the overall "tone" in the theater becomes much more tense when equipment acquisition and placement is not well-orchestrated. The surgeon is more likely to be successful in clearing the ductal system when such chaos is minimized.

Preparation for Laparoscopic Common Duct Exploration

Cholangiography

Intra-operative cholangiography is an essential part of successful common bile duct exploration. [29-41] Documentation of the ductal anatomy and the number and size of stones in the duct facilitates selection of the best approach and the equipment needed. Either the portal technique, first described by Reddick in 1989, or the percutaneous technique, developed by Petelin in 1990, may be used for placement of the cholangiocatheter. [42]

The percutaneous approach, however, is often preferred because it does not occupy one of the ports that might otherwise be used for retraction or manipulation of the gallbladder. Additionally, it offers an access site for either balloon-tipped catheters or stone retrieval baskets that are used during the ductal exploration.

Although static films may be used for cholangiographic documentation, they have the disadvantage of requiring considerably more time to complete, and the films obtained are often inadequate. Fluoroscopic cholangiography provides much more information much more quickly to the surgeon. The fluoroscope is also often very useful in managing ductal exploration when non-choledochoscopic methods are used. This will be discussed in detail later.

Dissection of the Porta Hepatis

It is more common for choledocholithiais to be present in older patients, and it is not uncommon for these patients to have a significant inflammatory reaction in the porta hepatis when they finally present to the surgeon. For this reason, the initial approach to the Triangle of Calot should proceed from lateral to medial. Dissection should be initiated lateral to the neck of the gallbladder if possible. If the degree of inflammation is so severe that this area cannot be defined accurately, then dissection should start higher on the gallbladder and descend to the neck. After the gallbladder-cystic duct junction is identified, the Triangle of Calot is approached. The cystic duct is identified, and the cystic artery is identified if possible. Cholangiograms are then obtained.

Notice that no mention has been made of identification of the cystic duct-common bile duct junction at this point. Although the common duct may have been already located at this time, the added dissection necessary to skeletonize the cystic-common duct junction, especially in the patient with severe inflammation, is not warranted. This is not to say that accurate identification of the structures in the porta hepatis isn't important. Proper identification is essential prior to clipping, ligating, or cutting into any structure in this area. However, in most cases, the dissection necessary to obtain cholangiograms and to perform cholecystectomy is significantly less than that required to perform common duct exploration.

When cholangiograms demonstrate choledocholithiasis, it is usually necessary to dissect the tissues in the porta hepatis somewhat more aggressively in order to obtain access to the common bile duct. As the previous table illustrated, when severe inflammation limits safe dissection in the Triangle of Calot, a transcystic approach to common bile duct exploration is preferred.

Laparoscopic Transcystic Duct Exploration

Non-Choledochoscopic Maneuvers to Clear the Duct

There are a variety of techniques that may be used to clear the common bile duct without resorting to the use of a choledochoscope. [14, 43] These methods offer the benefits of requiring less equipment, less set-up time, and less invasiveness than choledochoscopic intervention. In most cases, the author employs at least one of them while awaiting preparation of the choledochoscope. Not infrequently, the duct is cleared before the scope has been completely prepared. These techniques are complementary to choledochoscopic techniques. The surgeon should not consider his laparoscopic common duct exploration repertoire complete without also becoming proficient with the choledochoscope.

Pharmacologic and Flushing Techniques

In cases where intraoperative cholangiograms demonstrate flow into the intrahepatic and common ducts, but no flow into the duodenum, and where small stones or debris are suspected to be the culprit, pharmacologic relaxation of the sphincter of Oddi is sometimes successful in clearing the duct. Glucagon, 1 to 2 mg, is administered intravenously by the anesthetist. The surgeon then flushes the cholangiocatheter with saline and subsequently with contrast material in order to obtain a normal cholangiogram. This technique may be successful in clearing small stones (< 2mm) or debris, but the surgeon should not be fooled into thinking that 4 to 5 mm stones are likely to be cleared by this method.

Balloon Techniques

Low pressure balloon-tipped catheters may be introduced through the percutaneous cholangiogram sleeve into the cystic duct and into the common bile duct. A 4 French Fogarty catheter is usually most effective, and fits nicely through a 14 gauge sleeve in the abdominal wall. This catheter is guided through the ducts with forceps introduced through the medial epigastric port.

The author attempts to advance the catheter all the way into the duodenum if this can be done without excessive force. The tip of the catheter will usually enter the duodenum at 8 to 10 cm from the transcystic cannulation site, no matter where the cystic duct incision is located. The author has confirmed this finding in over 100 cases. In some cases, it is generally believed, although not irrefutably confirmed, that small stones or debris are actually forced into the duodenum with this maneuver.

The balloon is inflated in the duodenum, and the catheter is withdrawn with forceps in the medial epigastric port. When the duodenum is observed to move with the movement of the catheter, traction is ceased, the catheter is withdrawn 1 cm, and then the balloon is re-inflated. Traction is then resumed until the balloon appears at the cystic duct cannulation site. Occasionally, small stones or debris are delivered through the cystic duct with this method.

Critics of this maneuver raise the possibility of forcing stones into the hepatic ducts as a major disadvantage. Interestingly, however, the author has not experienced those untoward consequences with this technique. Certainly, stones may infrequently migrate into the hepatic duct, but they are easily displaced back into the distal duct by irrigating the duct with saline or contrast material while changing the patient position by tilting the operating table. More commonly, the stones are either delivered through the cystic duct or not affected in their position at all by balloon manipulations.

Basket Techniques

Stone retrieval baskets may also be inserted through the 14 gauge sleeve used for cholangiography. While either helical (Dormia type) or straight (Segura type) baskets may be used, this author prefers the straight 4-wire configuration because the larger interstices between the wires seem to allow easier stone capture. Some authors have recommended using only baskets with soft filiform tips in order to avoid damage to the duct. This does not appear to be absolutely necessary, however, because we have experienced no ductal injuries with non-filiform type baskets used in over 300 laparoscopic common bile duct explorations. It is important to use these baskets with extreme care and to avoid excessive force that might damage the duct.

With Fluoro

Many surgeons prefer to use the free basket technique with fluoroscopic guidance. Here, the duct is filled with contrast material through the cholangiocatheter and the location of the stone(s) is documented. The basket is then inserted through the 14 gauge sleeve into the duct and manipulated with forceps inserted through the medial epigastric port. The position of the basket and stone(s) is monitored with the fluoroscope. Stone capture is confirmed fluoroscopically.

Disadvantages of this approach include the increased radiation exposure to the team, and the difficulty of manipulating the basket with forceps while the C-arm of the fluoroscope is in position over the patient. This latter problem is significant. It is extremely difficult to maneuver the basket without using forceps, and the most common site through which these forceps are introduced is the medial epigastric port. Movement of the forceps is invariably obstructed by the C-arm unless extensive and/or excessive alterations of the scope position are made. Although an additional port may be placed to allow forceps manipulation of the basket, selecting a good site is difficult because of the existing ports and laparoscope.

Without Fluoro

The disadvantages encountered with the fluoroscopically-directed method, caused the author to develop a free basket stone capture technique without the use of the fluoroscope. Certain conditions must obtain, however, before such an attempt is made. First, the surgeon must know the course and approximate length of the cystic duct. This may be accomplished with cholangiograms and the use of the calibrated balloon-tipped catheter. Secondly, the basket must be calibrated lengthwise, so that its tip location may be known by the surgeon. Thirdly, the surgeon must control the handle of the basket himself and know the location of the sliding mechanism when the basket is completely open and completely closed. This will allow him to realize when the basket is only partially closed, as is the case when a stone is captured.

In this method, the basket is inserted as described above, but no fluoroscope is used to monitor the tip location. Its location is calculated by the surgeon using the above-mentioned factors. The basket is placed in the distal duct and then gradually withdrawn as the basket is closed. This step may need to be repeated numerous times before a stone is captured. Stone capture is signalled by incomplete closure of the sliding mechanism on the basket handle. The basket is then withdrawn through the cystic duct with the stone in place.

Great care must be taken that the basket is not advanced too far into the duct. If this occurs, "capture" of the papilla may result. This is difficult to release and presents the risk of pancreatitis if not managed judiciously. It is also important to avoid excessive force with basket manipulations in order to avoid perforation of the duct.

Choledochoscopy

Preparing the cystic duct for choledochoscope entry

In order to pass the choledochoscope through the cystic duct easily and safely, the internal diameter of the duct must be large enough to accept the scope. Conversely, the scope must be small enough to enter the duct. Generally, only the newer generation scopes with an external diameter < 3 mm are suitable for this approach. When the cystic duct diameter is smaller than the scope, attempts to dilate it may be useful.

This should only be attempted, however, after careful consideration of the factors listed in Table 1. In particular, if the cystic duct is less than 2 mm in internal diameter, then it will most likely not be possible to safely dilate it to twice its diameter, 4 mm, which would be necessary for easy scope introduction. In this situation, transcystic choledochoscopic exploration should not be attempted. Alternative methods, including non-choledochoscopic transcystic techniques or direct choledochotomy (only if cbd diameter > 6 mm) should be considered.

Three tools are available to dilate the cystic duct: curved forceps, mechanical graduated dilators, and pneumatic high-pressure balloon dilators. In situations where the cystic duct is relatively short and nearly large enough to accept the choledochoscope, curved tapered forceps may be inserted into it and gently opened to expand the duct. This method is quick and does not require any extra equipment.

Mechanical, over-the-wire graduated dilators are the next least expensive way to dilate the duct. These are inserted sequentially over a 0.035 inch guide wire which has been passed through the mid-clavicular port, the cystic duct and into the common duct. These dilators are inexpensive, and are usually available in the urology department of most hospitals. Care must be taken, however, when using this method so that excessive shearing force is not applied to the cystic-common duct junction. I have found that if the cystic duct will not initially and easily accept a 9 French dilator, that adequate dilatation to an 11 or 12 French diameter (which is necessary for easy passage of the new generation choledochoscopes) will not be possible.

The most expensive way to dilate the cystic duct involves pneumatic dilators. This type of dilator is advanced over a 0.035 inch guide wire through the cystic duct and into the common duct. The balloon is inflated to a pressure of approximately 5 to 7 atmospheres with saline administered via a screw-type syringe. The pressure is monitored with a gauge attached to the syringe. The physical changes in the duct must also be monitored laparoscopically. It is generally believed that the radial dilatation forces exerted by this type of balloon are safer than those shearing forces generated by graduated mechanical dilators.

If the cystic duct is long, tortuous, or if it enters the common duct posteriorly, then transycstic choledochoscopy will be difficult. In some of these cases, scope passage may be facilitated by "unwrapping" the cystic duct from the common duct. This requires more dissection laterally and posteriorly to cystic duct, but dissection should not be carried so far as to risk injury to the common duct, portal vein, or pancreas. This dissection should only be attempted by experienced laparoscopic biliary tract surgeons who are capable of distinguishing the anatomy and safely manipulating the fragile tissues in this area. Rotating the patient to the semi-left lateral decubitus position and employing an angled (30o) scope will promote easier dissection in this area.

Choledochoscope insertion

The choledochoscope is inserted through the mid-clavicular port into the cystic duct. While I prefer guiding the scope into the cystic duct with atraumatic forceps introduced through the medial epigastric port, two other options are available: insertion over a 0.035 inch guidewire, and insertion through a sleeve that has been already advanced into the cystic duct. [16] Forceps manipulation of the scope offers the advantage of superior control of the scope, which is especially useful in "difficult-to-cannulate" cases. It must be performed with atraumatic forceps and with great care in order to avoid damage to the skin of the scope. The guide wire method of scope introduction is relatively simple, but often requires added manipulation of the scope with forceps in order to overcome the resistance encountered in long or tortuous cystic ducts. This method can be invaluable in cases where the course of the cystic duct, not its diameter, seems to limit scope introduction. The use of a sleeve to guide the scope into the cystic duct provides the utmost protection for the scope, but requires that all manipulations occur outside the abdomen. This can limit the surgeon's ability to negotiate long or tortuous ducts. Additionally, it requires removal and subsequent reinsertion of the sleeve when stones larger than the sleeve are captured.

Negotiating the ducts

Cystic duct

After the scope is inserted into the cystic duct, it must be advanced into the common bile duct. Negotiating the cystic duct is usually the most difficult part of this task. There are a number of tips that can make this easier. First of all, the gallbladder should be retracted in such a way as to straighten the cystic duct as much as possible without producing excessive tension on it. This may require cephalad traction or lateral traction on the neck of the gallbladder, or more rarely, inferolateral traction on it. Secondly, the choledochoscope should be introduced from the abdominal wall to the cystic duct via the shortest and most direct route. Angulation of the scope inside the abdomen prior to entry into the cystic duct prohibits intrinsic scope movements such as rotation and angulation that are often necesssary to traverse the cystic duct. Thirdly, the surgeon should not hesitate to use a combination of forceps-directed scope advancement, rotational scope movement along its own axis, and deflecting movements of the scope tip in order to maneuver through the ducts.

Common duct

Distal

Once the scope is located in the common duct, distal movement is usually quite stratightforward. In most cases, axial advancement of the scope through the mid-clavicular port with the surgeon's left hand will guide the scope to the ampulla. Occasionally, torquing motion of the scope at this cannula site, combined with deflecting movements of scope tip are necessary to keep the scope in the center of the lumen of the duct. Great care must be excerised when the ampulla is reached so that excessive force is not applied to the papilla; mistakes here can result in pancreatitis or post-operative stricture. Attempts to advance the scope into the duodenum should not routinely be made unless the orifice is patulous or the patient has already had a sphincterotomy.

Proximal

Inspecting the proximal ductal system through a transcystic approach is only rarely possible. It generally requires a relatively short cystic duct the enters the common duct laterally at a 90o angle. In most cases, however, the cystic duct joins the common duct at an angle directed toward the distal common duct. This prohibits deflection of the scope into the proximal ductal system. Although critics of the transcystic approach cite this as a major drawback, proximal exploration is only rarely needed, and in these cases a choledochotomy approach may be used. In cases where stones are located in the proximal ducts, they can frequently be flushed into the distal system by irrigating the ducts while the patient position is altered. The stones can then be easily accessed in the distal duct. Completion cholangiograms are used to insure that proximal ductal system is free of stones or other pathology.

Using baskets with the choledochoscope

Segura vs. Dormia--Straight versus Helical Configuration

Inspecting the ductal system for stones is only useful if those which are identified are retrieved at that time; otherwise it is a useless and expensive exercise. Choledochoscopic stone retrieval is most commonly achieved by using a basket inserted through the channel of the scope. Most experienced laparoscopists prefer to use the straight configuration (Segura type) baskets in this situation because the interstices between the wires are large enough to capture most stones. Additionally, straight baskets don't require axial rotating movements of the shaft of the basket that are required with the Dormia type basket in order to capture stones.

If a larger basket is required to capture stones, it will most likely not fit into the scope channel; in this case, it may be inserted adjacent to the scope if the diameter of the cystic duct will permit. Capture may still be performed under direct vision although manipulations of the basket may be somewhat more difficult since it doesn't move with movement of the scope tip.

Techniques

Surgeon control

The scope is inserted through the mid-clavicular port by the surgeon, not the assistant or the nurse. It is guided into the cystic duct and advanced through the common duct by the surgeon, not the assistant or the nurse. Negotiation of the ductal architecture and localization of stones is managed by the surgeon. This requires that both of the surgeon's hands manipulate the choledochoscope. Generally, the left hand produces axial (to-and-fro) and rotational motion at the cannula insertion site on the abdominal wall, while the right hand controls deflection of scope tip with the deflection lever on the scope handle.

Left hand control must insure that the scope is not angulated at all at the cannula insertion site. Otherwise, significant scope damage will occur. In order to do this, the left hand controls the cannula with the 4th and 5th fingers and the scope shaft with the thumb and 1st finger. It is nearly impossible to angulate the scope at the cannula insertion site with this approach.

Right hand control insures that the external portion of the shaft of the scope is not twisted severely, producing excessive tension on the internal mechanism of the scope. This control must also guard against inordinate pressure on the deflection mechanism of the scope. This will not only protect the patient from injury, but will also extend the longevity of the choledochoscope.

After the most proximal stone is localized, the surgeon must insert a basket through the working channel of the scope. In order to do this, he must transfer control of the scope at the cannula insertion site to the assistant. He must instruct the assistant to accept this control with exactly the same force(s) as he is exerting on the equipment in order to keep the stone in choledochoscopic view. The surgeon then inserts the basket through the working channel of the scope until its tip passes the stone. The basket handle is then opened and to-and-fro movement of the basket around the stone is made until capture occurs. At that point the basket is closed gently around the stone and the entire ensemble is removed through the cystic duct.

Assistant duties

Laparoscopic choledochoscopy is quite difficult to perform with an inexperienced team. Nursing duties, including acquisition and placement of equipment have already been described. The first assistant's role is no less important. When the scope control at its insertion site in the mid-clavicular cannula is transferred to him, he must provide the same axial and rotational forces to the scope as the surgeon did, and direct his undivided attention to the field and video monitor to insure that the stone remains in view. This is important because the channel into which the surgeon will insert the basket is the same channel through which saline installation has been provided to distend the common duct. Since the basket nearly fills the lumen of this channel, no further significant installation is possible during this time. This means that if the stone is not immediately in view, and if further scope manipulations are necessary to find it, that adequate distention of the duct will most likely not be possible. Additionally, the presence of the basket in the channel stiffens the choledochoscope, making negotiation of the ductal system more difficult. All of these factors usually lead to removal of the basket from the channel, re-installation of saline to distend the duct, and scope manipulations to once again find the stone.

Using balloon-tipped catheters with the choledochoscope

In some situations it is helpful to use a balloon-tipped catheter with the choledochoscope. These catheters generally don't fit in the working channel of the newer small diameter scopes, so they must be inserted adjacent to the scope. This obviously requires that the cystic duct diameter is large enough to accept both instruments. This combination of instruments is useful to capture stones that are larger than the largest available basket, stones that defy capture at the papilla, and intrahepatic stones.

In each of the situations, the balloon is passed distal to the stone, inflated, and withdrawn enough to trap the stone against the scope. The entire ensemble is withdrawn in unison from the duct, expressing the stone onto the tissues near the cystic duct. It is then removed with forceps inserted through the medial epigastric port.

Approaching the Common Bile Duct

There are a number of situations in which a purely transcystic approach is not adequate to clear the ductal system. In some cases, the cystic duct will not allow passage of the choledochoscope; in others, although scope passage is permitted, and stone capture accomplished, the stone is too large to allow removal through the cystic duct. These situations do not necessarily require that a "formal" choledochotomy must be made.

Instead, in some cases, the cystic duct orifice that had originally been created by the surgeon, may be extended toward the common duct. This is accomplished by advancing scissors through the medial epigastric port into the orifice and cutting the cystic duct wall longitudinally toward the common duct. The incision is lengthened as needed to either accept the choledochoscope or to allow removal a stone which has already been captured, but defies exit through the cystic duct. In some cases, the incision only needs to be extended to a wider-diameter portion of the cystic duct. In others, the extended incision will actually abut or include the cystic duct-common duct junction. In the latter situation, closure of the duct usually requires suturing. Most often, this is accomplished without the placement of a T-Tube, unless of course there are good reasons for leaving a tube in place, such as ampullary spasm or concern about adequacy of clearance of the ductal stones. Knots are best secured here using an intracorporeal technique of tying rather than an extracorporeal method because the latter provides more risk of tearing the suture through the duct wall.

Caution must be exercised here. The length and course of the cystic duct must be carefully evaluated. If it enters the common duct posteriorly or quite distally, and if its caliber is uniform throughout, then extension of the initial orifice will be useless and potentially troublesome. This technique of extending the cystic duct opening obviously works best in patients with a relatively short cystic duct which enters the lateral aspect of the common duct. If this situation does not obtain, then an alternative method should be considered.

The short cystic duct

In the patient with the extremely short cystic duct it is quite easy to consider extension of the cystic duct orifice onto the common duct in order to remove large common duct stones. Interestingly, however, it seems that most patients in this situation usually have a rather large diameter cystic duct that allows retrieval of even sizable stones. The major problems with the short cystic duct are usually those of its closure after the common duct has been cleared. For the reasons mentioned above, it is often not possible to secure it with a clip or a pre-tied ligature. Suture closure with intracorporeal knot tying techniques are preferred in this case.

The long cystic duct and the posterior cystic-common duct junction

These situations have been referenced elsewhere in this chapter but deserve further discussion. The issue here is really one of recognition. With experience in laparoscopic biliary tract surgery, the surgeon should acquire the ability to identify the long cystic duct or the posterior cystic duct-common duct junction early in the case. This sounds somewhat simplistic, but every surgeon who has spent any time in the right upper quadrant realizes that the long cystic duct often initially appears to be rather short with an entry into the lateral aspect of the cystic duct. It is only after further dissection, or more preferably, intraoperative cholangiograms that the true course of the duct becomes evident. Recognition of this fact early in the case provides the surgeon with enough time to formulate his plans for an approach to the common duct that will most likely result in successful clearance of the stones. Alternatively, if the surgeon has not established a mental picture of the extrahepatic biliary tract anatomy until he is faced with the task of common duct exploration, he will likely flounder aimlessly in the porta hepatis employing techniques which have little chance of success.

The importance of surgical interpretation of the intraoperative cholangiograms cannot be overstated. The surgeon must be facile with manipulation of the C-arm of the fluoroscope. He must also recognize the subtleties of complex double contrast enhancement which indicate overlapping ductal structures. This information, coupled with the gross visual presentation, provides excellent clues to the true 3-D configuration of the ductal system. This information is so important that without it, successful completion of laparoscopic common duct exploration would be more a matter of blind luck than surgical skill.

Stones larger than the cystic duct

Not infrequently, the cystic duct approach will allow capture of common duct stones which are larger than the diameter of the cystic duct. This situation has a number of possible solutions. First of all, the stone may be withdrawn to the cystic duct junction and crushed gently with atraumatic forceps applied to the duct wall at that point. Obivously, this must be done with great care to avoid damage to the duct. The potential disadvantages of this maneuver include loss of the stone back into the common bile duct or production of multiple stone fragments where only one previously existed. Nevertheless, this technique is successful more often than it is not, and has not to this date resulted in the above-mentioned complications.

The second solution to this problem involves extending the cystic duct orifice longitudinally toward the common duct until the stone is removed. This should only be attempted if the cystic duct-common duct junction is located laterally and is readily apparent. This maneuver is accomplished by retracting the stone-filled basket through its own port while scissors inserted through the medial epigastric port are used to incise the cystic duct through the existing opening.

Results

In the short time that laparoscopic biliary tract surgery has been practiced, tremendous success with transcystic common bile duct exploration has been documented by a number of authors. The degree of success relates not only to the expertise and dedication of these individuals, but also to the patient population and the type of stones which are encountered. Results of some of the larger series are demonstrated in Table 2.

Table 2.

Surgeon	Year	Total LCDE Cases	TransCystic Route	%	Choledo- chotomy Route	%	Total Successful Clearance	%	Mortality	%
Petelin	1991	22	20	91	1	5	19	86	0	0.0
Shapiro	1991	16	15	94	1	6	16	100	0	0.0
Hunter	1992	20	20	100	0	0	17	85	0	0.0
Petelin	1993	77	75	97	2	3	74	96	1	1.3
Fielding, et.al.	1993	21	20	95	1	5	17	81	0	0.0
Fletcher	1993	12	12	100	0	0	8	67	0	0.0
DePaula	1994	119	107	90	12	10	108	91	1	0.8
Phillips, et.al.	1994	120	111	93	9	8	112	93	1	0.8
Dion, et.al.	1994	59	18	31	41	69	52	88	0	0.0
Ferzli, et.al.	1994	24	13	54	11	46	24	100	0	0.0
SAGES Study	1994	226	188	83	38	17	210	93	1	0.4
Franklin	1995	113	2	2	111	98	112	99	1	0.9
Phillips, et.al.	1995	162	145	90	17	10	150	93	1	0.6
Rhodes, et.al.	1995	129	94	73	35	27	119	92	0	0.0
Millat, et.al.	1995	115	80	70	35	30	100	87	0	0.0
Lezoche, et.al.	1996	100	67	67	33	33	96	96	1	1.0
Motson, et.al.	1996	60	46	77	14	23	56	93	0	0.0
EAES Study	1996	82	42	51	40	49	68	83	1	1.2
Petelin	1996	197	173	88	24	12	189	96	1	0.5
Drouard, et.al.	1997	161	60	37	101	63	148	92	0	0.0
Millat, et.al.	1997	236	134	57	102	43	208	88	1	0.4
Gigot, et.al.	1997	92	62	67	30	33	77	84	2	2.2
Rhodes, et.al.*	1998	40	28	70	12	30	30	75	0	0.0
Lezoche, et.al.	1998	161	109	68	52	32	157	97	1	0.6
Franklin, et.al.	1998	148	3	2	145	98	140	95	1	0.7
DePaula	1998	181	147	81	34	19	170	94	1	0.6
Petelin	1998	243	206	85	37	15	235	97	1	0.4

Note: Some authors are listed more than once to show series evolution over time

*This series is reported from a different institution with other associates. No choledochoscopic methods were used.

Notice that some authors appear more than once. These repeated entries are included to demonstrate longitudinal follow up of individuals; each successive entry incorporates the outcomes of previous reports of that particular series in prior years.

Not all patient populations will harbor stones which will be amenable to transcystic duct removal. Certainly, Franklin has a patient population which generally has significantly larger stones than those of the patient populations of Phillips and Petelin. This fact bears upon the "preferences" of approach for laparoscopic common duct exploration route by various authors

Conclusions

Laparoscopic choledocholithotomy has been shown to be feasible, safe, and highly effective in the management of choledocholithiasis. While both a choledochotomy approach and a transcystic approach are effective, the transcystic route of common bile duct access for ductal exploration represents the "ultimate" in maintaining a minimally invasive surgical approach to biliary tract disease.

Patients, insurers, and referral physicians in the current era demand the least invasive, most efficient, and cost-effective treatment modalities for surgically-treatable disease. Therefore, biliary tract surgeons should consider laparoscopic choledocholithotomy an essential component of the protocol for the management of choledocholithiasis. Surgeons are challenged to become proficient in these minimally invasive techniques for clearance of common bile duct stones in one setting, rather than in a series of secondary, expensive, time-consuming, and potentially debilitating, therapeutic procedures.

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6. Transductal Choledochoscopy

Morris E. Franklin Jr., MD, FACS

Professor of Surgery; University of Texas Health Science Center at San Antonio; Director, Texas Endosurgery Institute

J. Arturo Almeida, MD

Fellow, Texas Endosurgery Institute; 4242E Southcross Blvd, suite 1; San Antonio, TX 78217

www.texasendosurgery.com

Since the acceptance of laparoscopic surgery as the gold standard for biliary surgery, management of choledocholithiasis has evolved subsequently. It is estimated the prevalence of this disease to be between 8-15% in patients younger than 60 years and increases with age, up to 15-60% prevalence rate. The routine use of intraoperative cholangiogram (IOC) done by some surgeons at the time of laparoscopic cholecystectomy also leads to identify patients with totally unsuspected choledocholithiasis. At the beginning of the laparoscopic era a preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy was performed to clear the common bile duct followed by laparoscopic cholecystectomy, and yet this is the preferred approach by many surgeons, particularly in Europe. As more advanced instrumentation was available and laparoscopic skills improved, treatment of common bile stones was accomplished laparoscopically, either by trans-cystic or transductal common bile duct exploration exploration during the same surgical procedure. The results reported by several groups from around the world show that this one-stage laparoscopic approach is feasible, safe and avoids the necessity of a second invasive procedure (ERCP), which in fact is not free of potentially serious complications and has an established mortality rate (1%). ERCP is not always successful and we have treated patients who have undergone ERCP and were referred to us when stones were demonstrated but could not be removed by sphincterotomy and basket extraction. Furthermore, sometimes opening the common bile duct for diagnosis or definitive treatment of a given bile duct disease is necessary.

Since 1990 we have performed routine IOC in 100% of our laparoscopic cholecystectomies, with a 99% success rate. This allowed us to gain familiarity with the anatomy of the biliary duct system and identify patients with known or totally unsuspected stones in the common bile duct (CBD). We also feel very strongly that a road map to the biliary system is mandatory for successful completion of laparoscopic common bile duct exploration (L-CBDE). We started early in our experience to treat patients with choledocholithiasis during the same laparoscopic procedure as we felt this to be the best way to approach these patients.

Technique of Transductal Choledochoscopy

The OR setup is the standard for a routine laparoscopic cholecystectomy. Patient is in the supine position. Four trocars are used and a 0∞ scope is inserted through the umbilicus port. After completion of the cholangiogram, if stones are demonstrated in the CBD, this is exposed by incising the peritoneum that overlies it. In extremely obese patients this can be somewhat tedious procedure and there can be a moderate amount of bleeding that is controlled with the pinpoint, low energy electrocautery. A 1- to 2-cm margin on the anterior surface of the common bile duct is exposed and a vertical incision is made. We do not use stay sutures for securing the CBD; instead, we grasp the cystic duct and elevate it, resulting in adequate visualization and ready access to the choledochotomy.

After completion of a choledochotomy, direct visualization is possible, and stones can be removed from the CBD on an individual basis, or by irrigation. A #4 or #5 Fogarty catheters can also be used for moving stones at the initial exploration of the duct.

The choledochoscope is then introduced through the subxiphoid port and the endoloop guide is used to carry the scope into the peritoneal cavity down to within 2 cm of the choledochotomy. The choledochoscope should have a readily adaptable eyepiece for auxiliary monitor viewing. We routinely use a third monitor setup, along with its light source, for performing the transductal choledochoscopy. A scope that will flex in two directions is much better than a unidirectional flexing scope because greater maneuverability inside the abdominal cavity as well as in the duct is possible. The choledochoscope is then placed in the CBD opening and flexed as is appropriate for proximal and distal examination of the duct. We routinely explore the proximal portion of the CBD initially, and feel that irrigation during this part is mandatory to successful exploration. We currently use the Nehzat-Dorzet® pump system, which supplies greater than gravity pressure to the irrigation system, but other commercially available systems may be used as well. After clearance of the proximal ductal system, the scope is passed distally, where at least 70% of the stones are located. The stones are individually identified and removed with a basket or a grasper-type device. The usage of these baskets requires some degree of practice by the operating surgeon. As stones are individually extracted from the CBD they can be removed one by one from the peritoneal cavity, but more efficiently are placed on the surrounding omental area for later placement into the specimen retrieval bag with the gallbladder, which is not removed until the L-CBDE is completed. After all stones have been removed, the sphincter can be readily visualized in 90% of the cases and in approximately 20 to 25% of the cases, the choledochoscope can be passed directly into the duodenum in order to perform duodenoscopy. A laparoscopic antegrade sphincterotomy can also be performed if needed. A second intraoperative cholangiogram is taken through the choledochoscope to ensure that the distal portion of the duct is clear. If the duct is clear and dye flows into the duodenum, the scope is withdrawn and preparations are made for placement of a T-tube. Very briefly, we use smaller tubes (8 to 10F) as they are easy to manipulate laparoscopically. The T-tube is tailored to facilitate its placement into the CBD and the choledochotomy is then closed with interrupted 4-0 Vicryl® sutures. We have developed a special knot that allows special slippage and rapid subsequent placement of a second throw. After placement of the T-tube, the free portion is brought out through the subcostal trocar and a T-tube cholangiogram is taken to be sure closure of the choledochotomy is adequate, as well as to find possible residual stones and ensure proper drainage through the sphincter. Then the T-tube is reintroduced into the abdominal cavity.

Upon completion of this part of the procedure, the cystic artery is double clipped and divided, and the remainder of the laparoscopic cholecystectomy is performed. The gallbladder is placed inside a specimen retrieval bag together with the CBD stones previously extracted.

The postoperative course is normally benign, with most of our patients staying in-hospital less than 48 hours. There have been no major complications with this technique, save the death of one patient who had a myocardial infarction 24 hours postoperatively. We routinely remove the T-tube in approximately 10 days, after a T-tube cholangiogram has been obtained.

Conclusion

Very little specialized equipment, besides the availability of a choledochoscope, is needed for this procedure. However, it mandates the surgeon to have advanced laparoscopic skills, including intracorporeal suturing, besides the ability of manipulating a flexible choledochoscope and wire baskets. It is also important to have a trained surgical team. We feel these new procedures are cost-effective and can be safely performed. Now the task is to improve the laparoscopic skills of a sufficient number of surgeons, as well as to improve training of surgery residents, so they can perform these procedures in a safe and efficacious manner.

SUGGESTED REFERENCES.

1. Yamakawa T. Sakai S. Mu ZB. Pineres G. Laparoscopic management of common bile duct stones. Journal of Hepato-Biliary-Pancreatic Surgery. 7(1):9-14, 2000

2. Lauter DM. Froines EJ. Laparoscopic common duct exploration in the management of choledocholithiasis. American Journal of Surgery. 179(5):372-4, 2000 May

3. Memon MA. Hassaballa H. Memon MI. Laparoscopic common bile duct exploration: the past, the present, and the future. American Journal of Surgery. 179(4):309-15, 2000 Apr.

4. Michel J. Navarro F. Montpeyroux F. Burgel JS. Le Moine MC. Daures JP. Drouard F. Berthou JC. Fabre JM. Domergue J. Treatment of common bile duct stones with laparoscopy. Retrospective multicenter study with 612 patients. Gastroenterologie Clinique et Biologique. 24(4):404-8, 2000 Apr

5. Giurgiu DI. Margulies DR. Carroll BJ. Gabbay J. Iida A. Takagi S. Fallas MJ. Phillips EH. Laparoscopic common bile duct exploration: long-term outcome. Archives of Surgery. 134(8):839-43; discussion 843-4, 1999 Aug

6. Snow LL. Weinstein LS. Hannon JK. Lane DR. Management of bile duct stones in 1572 patients undergoing laparoscopic cholecystectomy. American Surgeon. 65(6):530-45; discussion 546-7, 1999 Jun

7. Crawford DL. Phillips EH. Laparoscopic common bile duct exploration. World Journal of Surgery. 23(4):343-9, 1999 Apr

8. Dorman JP. Franklin ME Jr. Glass JL. Laparoscopic common bile duct exploration by choledochotomy. An effective and efficient method of treatment of choledocholithiasis. Surgical Endoscopy. 12(7):926-8, 1998 Jul

9. Dorman JP, Franklin ME Jr. Laparoscopic common bile duct exploration by choledochotomy. Seminars in Laparoscopic Surgery. 1997 Mar; 4(1):34-41

10. Franklin ME Jr: Laparoscopic choledochotomy for management of common bile duct stones and other common bile duct diseases. In: Principles of Laparoscopic Surgery. Basic and Advanced Techniques. Maurice Arregui, ed. New York. Springer-Verlag Publishers. 1995:197-204, 12.5.

11. Franklin ME Jr, Pharand D, Rosenthal D. Laparoscopic commom bile exploration. Surgical Laparoscopy and Endoscopy 1994 Apr;4(2):119-124

7. Complications of Laparoscopic Common Bile Duct Exploration

Richard M. Vazquez, M.D.

Assistant Clinical Professor of Surgery

Northwestern University Medical School

Shortly after the introduction of laparoscopic cholecystectomy by Olsen and Reddick, reports of clearance of the common bile duct of stones by intra-operative laparoscopic common bile duct exploration (L-CBDE) by surgeons began to appear in the medical literature.1,2 As with any other surgical endeavor, reports of complications of laparoscopic CBDE also started to appear.3

Most surgeons prefer to explore the common bile duct by the transcystic duct route. The morbidity associated with the transcystic approach is 8% minor complications, 6% major and <1% mortality

with death usually being due to comorbid illness.4 Time consuming suture closure of the common bile duct with or without "T" tube placement is obviated. Since the average hospital stay of a patient who has a transcystic duct common bile duct exploration is 1.5 days, longer stays are frequently associated with the occurrence of complications. Complications not directly related to operative procedures such as postoperative pneumonia and atelectasis are infrequent in the laparoscopic postoperative patients, therefore, the component portions of the operations known to possibly result in complication need to be exonerated by objective studies. The incidence of postoperative wound infection seen with open common bile duct exploration has been reduced to essentially zero from 0.6% by minimally invasive surgery. Therefore, the minimally invasive surgeon should search for morbidities due to components of the operation if the transcystic L-CBDE patient is not thriving at home within 24 to 48 hours postoperatively. Similarly, patients should be home and thriving within 24 to72 hours postoperative after a successful direct choledochotomy L-CBDE.

The complications specific to L-CBDE fall into several broad categories:

1. Failure of the procedure to clear the common bile duct of stones

2. Bile leaks and consequences thereof e.g., abscess

3. Injuries to the bile ducts or other structures

4. Pancreatitis

5. Aspiration pneumonia due failure to decompress stomach of irrigant

6. More than one of the above

Since avoidance of the complications remains preferable to the treatment of the complications, methods that we can employ to avoid complications are discussed first.

How to avoid unnecessary L-CBDE and retained stones

An unnecessary procedure cannot benefit the patient but does provide the patient with the opportunity to develop all of the complications of the procedure. Digital fluoroscopic intraoperative cholangiography (IOC) with a C-arm, especially one equipped with a video disc and/or VCR for capture of dynamic video cholangiography, can greatly enhance the usefulness of the initial IOC and completion cholangiograms. Air bubbles can often be seen to change shape during the dynamic cholangiogram. L-CBDE or postoperative ERCP for air bubbles and not stones can be avoided. The memorialized real time video images can be reviewed with consultants during or after the operation. If doubt about the presence of retained stones persists after the above measures, then a transcystic duct tube such as the Fitzgibbons5 tube can be left behind for postoperative imaging or as an aid to ERCP. Most surgeons clear the CBD of stones in 80 to 90% of the explorations.5 That means that retained stones occur in 10 to 20% of the L-CBDE procedures. Intentionally abandoned small stones probably do not qualify as true complications since the expectation of the surgeon is spontaneous passage of the stones or that perhaps that small air bubbles and not stones were seen on the cholangiogram.

Not all preoperative ERCP/ES procedures result in clearance of the CBD.7,8 Routine IOC will decrease the number of undetected retained stones after ERCP, may add useful anatomic information during the laparoscopic cholecystectomy, and should avoid the embarrassing situation of a repeat ERCP postoperatively to zero by permitting a rescue L-CBDE.

Since the common hepatic duct can be accessed through the cystic duct with a choledochoscope only 10% of the times, stones above the cystic duct may not be visible to the surgeon. With only rare exception, completion cholangiography should be performed after L-CBDE. Therefore, stones outside the reach of the transcystic duct endoscope should not escape detection altogether. With all of the above in mind, the surgeon can then decide whether conversion to an open procedure is preferable to reliance upon postoperative ERCP for clearance of retained stones in any given circumstance. Some patients may be candidates for biliary bypass for stone disease and, depending on the laparoscopic suturing skills of the surgeon, may need to be converted to an open bypass procedure.9

Unsuccessful stone manipulation will likely set the stage for cholangitis if the CBD is obstructed distally and not decompressed proximally. This situation is not dissimilar from the cholangitis associated with unsuccessful ERCP with retained stones and may result in rapidly appearing sepsis.

How to avoid a potentially unsuccessful ERCP after laparoscopic cholecystectomy

The IOC may show stones that the surgeon intends to abandon to the hands of the interventional GI specialist. However, the presence of a duodenal diverticulum or impacted distal stone may make ERCP/ES unsafe or impossible. The quality of the local endoscopy talent must be taken into consideration when these decisions are being made. Strong consideration should be given to conversion to an open CBDE or the use of a lithotripsy instrument for the fragmentation of the distal impacted stone. The surgeon should consult with the gastroenterologist who will assume responsibility for this biliary tract problem during the operation. The gastroenterologist may prefer that the procedure be converted to open if unsuccessful or dangerous ERCP seems likely.

Bile leaks after L-CBDE

Troubleshooting the L-CBDE for bile leak is similar to investigation for bile leak after LC.10 Unfortunately, the ducts of Luska are not frequent causes of such leaks. Laboratory studies may be of some value, however, LFT's are frequently normal early in the course of a leak. The bilirubin rises as bile is re-absorbed from the peritoneal cavity. Mild hyperamylasemia may accompany a bile leak or even an injury to the duodenum or small bowel.

Abdominal tenderness and distention due to ileus occur frequently and are usually accompanied by anorexia. Rapid recognition of the existence of the leak and rapid correct treatment will decrease morbidity. A noninvasive study such as a HIDA scan may be useful to detect bile leaks. An ultrasound examination or CT scan may provide useful information about the existence of fluid (bile) collections. Usually a positive HIDA scan should be followed with an contrast imaging study, e.g. ERCP, PTC, or "T" tube cholangiogram in order to define the precise anatomy of a leak.

The bile leak may be due to the L-CBDE or the LC portion of the operation. Injury to a sectoral duct, the right, left, common hepatic or CBD need to be excluded. At the same time the security of the closure of the cystic duct can be evaluated. The passage of scopes and stones through the cystic duct may traumatize the cystic duct. Closure of the cystic duct even when more favorable methods than simple clip application are used may fail. The passage of wires and baskets through the common bile duct may directly injure the wall of the common bile duct. The suture line of the choledochotomy from a direct L-CBDE procedure or dislodgment of the "T" tube may occur.

The bile collection should be promptly drained and the biliary system decompressed by ERCP with stent placement. If the latter is not possible PTC with biliary tract drainage or an open procedure with the same goals may be required. Whichever method is selected, control of the source of the leak and drainage of the bile collection are the goals to be sought. Should the leak persist and the anatomy or volume of the of the leak suggest that spontaneous resolution is unlikely to occur, then laparotomy and operative correction of the problem will likely be required. Deterioration of the patient's general condition may force early laparotomy as well.

A leak from a bowel injury may present in a manner similar to a bile leak. Duodenal injury from the L-CBDE instruments may occur and of course bowel injuries may occur with any intra-abdominal laparoscopic procedure. The possible existence of a bowel injury presenting as though it were a bile leak is all the more reason to proceed with rapid investigation of the "bile leak" of the post L-CBDE patient. A low threshold for open exploration of the patient will help more patients than it will hurt.

How to avoid common bile duct stricture

The use of energy sources for cutting and coagulation near the CBD in preparation for L-CBDE may injure the blood supply to the CBD. Most troublesome bleeding can be controlled with pressure with subsequent clearing of the operative field by generous irrigation and suction.4 Precise application of clips to small vessels such as branches of the cystic artery that supply the cystic duct are preferable to the use of monopolar electrocoagulation near the CBD. Over dissection of the CBD may result in duct ischemia. The occurrence of such strictures may not be apparent immediately but may become apparent late after L-CBDE and LC.

Stone extraction from small common bile ducts (< 6mm diameter) especially through small cystic ducts may best be deferred to ERCP if possible. Small stones in CBD's can usually be flushed through the ampulla of Vater. Small size is one of the factors that determines whether primary repair of intra-operatively recognized common bile duct injuries will result in stricture of the CBD. Avulsion of the cystic duct during LC or L-CBDE from the CBD will require repair. Primary repair of an avulsed cystic duct in this situation may narrow the lumen of the CBD from resultant scarring and fibrosis. One method of managing this injury that may prove useful is placement of a "T" tube into the site of avulsion of the cystic duct. Postoperative ERCP/ES with placement of a stent into the CBD may be required to decompress the common bile duct. Conversion of the procedure to open may be required to fully evaluate the injury and to effect this option or other options for repair.

How to avoid postoperative pulmonary aspiration of irrigant

A lengthy L-CBDE may require the use of large amounts of saline irrigant through the choledochoscope. The irrigant should be suctioned from the stomach. If an orogastric tube was used, it may need to be replaced with a nasogastric tube. The nasogastric tube can usually be removed shortly after the operation when the patient can protect his or her airway.

How to avoid postoperative pancreatititis

Pancreatitis may antedate the L-CBDE or pancreatitis can be caused by the cholangiogram, trauma to the ampulla of Vater, or retained stones. Trauma to the ampulla can be minimized by not passing any large instrument or balloon through the ampulla. The endoscope may be used to gently push debris through the ampulla. It should not be used to forcefully dilate or pass through the ampulla.. The diagnosis of pancreatitis should be made in as secure a fashion as possible with appropriately high levels of serum amylase and lipase. These laboratory studies plus anatomic confirmation of pancreatitis with contrast CT scans will avoid the mistake of diagnosing a bile or bowel leak as pancreatitis.

If the pancreatitis persists a retained impacted stone is a real possibility, and postoperative ERCP/ES may be indicated to avoid the occurrence of severe pancreatitis.

How to avoid postoperative intra-abdominal abscess

It has now been rather well established that gallstones should not be abandoned in the abdominal cavity if at all possible. Gallstones may be spilled into the abdominal cavity during LC and are frequently deposited on the omentum for later disposal during L-CBDE. The stones should be gathered and removed prior to termination of the L-CBDE. Failure to do so may result in early or late abscess formation. Percutaneous drainage of the abscess may suffice to control the process, however an occasional patient may require open operation for drainage of the abscess and removal of the debris.

Summary

Single stage management of the patient with calculus disease of the gallbladder and bile ducts by laparoscopic common bile duct exploration continues to slowly increase in popularity. There will doubtless continue to be many successful operations, some failures, and occasional complications of this advancing therapy. Surgeons can avoid many of the complications by familiarizing themselves with the causes of the complications. Avoidance of the causative agents will continue to be the best method for minimizing postoperative complications of L-CBDE. Early recognition of the complications and proper and their timely and correct management will decrease patient morbidity and mortality.

Bibliography

1. Petelin J. Laparoscopic approach to common duct pathology. Surg Laparosc Endosc 1991; (1)33-41.

2. Shapiro SJ, Grundest W. Laparoscopic exploration of the common bile duct experience in 16 selected patients. J Laparendosc Surg1991; (1)333-341.

3.Berci G, Morganstern L. Laparoscopic management of common bile duct stones. A multi-institutional SAGES study. Surg Endosc 1994; 8(10)1168-74.

4. Friedman RL, Phillips, EH. Laparoscopic common bile duct exploration. In: Mastery of endoscopic and laparoscopic surgery. Ed: Eubanks, et al: Lippincott, Williams & Wilkins 2000; 29: 258.

5. Fitzgibbons RJ Jr, et al. Eight years experience with the use of a transcystic common bile duct double-lumen catheter for the treatment of choledocholithiasis. Surgery 1998; 124(4)699-705. discussion 705-6.

6. Lauter DM, Froines EJ Laparoscopic common duct exploration in the management of choledocholithiasis. Am J Surg 2000; 179(5)135-8.

7.Graham SM, Flowers Jl, et al., Laparoscopic cholecystectomy and common bile duct stones-the utility of planned peri-operative endoscopic retrograde cholangiography and sphincterotomy: experience with 63 patients. Annals Surg 1993; 218(1)61-7.

8. Poole G, et al. Laparoscopic common bile duct exploration after failed endoscopic stone extraction. Endoscopy 1997; 29(7)609-13.

9. Gurbuz AT, et al. Laparoscopic choledochoduodenostomy. Am Surg 1999; 65(3)212-14.

10. Ghahremani GG. Postsurgical biliary tract complications. Gastroenterologist 1997; 5(1)46-57.

8. The Role of Open CBDE

Luis E Burbano, MD

Proffesor of Surgery, Chief of Surgery

Hospital Metropolitano

P.O.Box 17-11-06556

Quito-Ecuador

Choledocholithiasis occurs in 6-15% of patients with cholethiasis.It's treatment continues to be a challenge for the surgeon who has to choose among several options available in this new era of gold standard laparoscopic cholecystectomy and new technology for succesful treatment of CBD stones.

Sages guidelines for the clinical application of laparoscopic biliary tract surgery, published in Surgical Endoscopy on August 2000,clearly state that a surgeon who performs a laparoscopic biliary procedure must be qualified to make the right decision to convert and carry on an open procedure.

The right decision, that is, the optimum management for the patient, will depend on two extremely important factors: the skill and experience of the surgeon, and the resources of the institution, that is the availability of highly skilled endoscopists and appropriate laparoscopic and surgical equipment.

The surgeon has to be aware of his personal results and those of his institution, regarding success, morbidity and mortality rates of different biliary tract procedures, so that he can make an appropriate judgement as to which are his best choices.

Let's review the most common scenarios so we can discuss the role of open CBD exploration:

Open CBDE in Cholecystitis, Cholethiasis and Suspected CBD Stones:

The E.A.E.S. multicenter trial comparing two-stage vs single stage management of patients with gallstone disease and ductal calculi published in Surgical Endoscopy in 1999 revealed no significant differences between the two approaches, except a shorter hospital stay with the one stage procedure.

An open CBDE continues to be an important and succesful procedure indicated in the following instances:

Failed canulation attempting a pre-op ERC(0-10%).Not enough experience in LCBDE.

Succesful ERC but stones not cleared.

Presence of predictors of ERC-ES failure, that is, stones larger than 25 mm, stones larger than the common duct, intrahepatic, impacted or multiple packed stones.In this situation,CBD stoned should be treated under the same anesthetic.

Laparoscopic cholecystectomy converted to an open procedure(1-6%) with CBD stones shown in pre-op ERC or intra-op cholangiogram.

Open CBDE in Unsuspected CBD Stones Found During IOC.

At the time of a LC the surgeon can perform an IOC and unsuspected stones can be discovered(2%).His debate as to what to do should consider his personal experience and the nature an quality of his resources, if he decides to continue with a LCBDE.His choices are to perform an open CBDE, a LCBDE, an intra-op ES, a post-op ERC and ES, or could decide to put his patient under observation if the stone is very small.(<3mm).

If the stones are large,multiple or impacted, his best choice may be to perform an open CBDE. A decision to leave large or multiple stones for post-op ERC and ES is unwise. Post op LC ERC can be equally succesful than pre-op ERC (95%),with succesful removal of stones(84%) if the above mentioned predictors of ERC failure are not present.

Open CBDE in Patients Who Have Had a Previous Open or LC:

If CBD stones are found in a patient who has had an open or LC, most surgeons would recomend an ERC and endoscopic removal of the stones. I would recomend an open procedure if predictors of ERC and ES failure are found.

If a failed canulation occurs and CBD stones are demostrated by ultrasound or magnetic resonance cholangiography, depending again on experince, skills and resources, a diagnostic laparoscopy can be made to investigate the real possiblity of exposing the common duct with de difficulties of previous surgery. If technically feasable and safe, a LCBDE can be performed, but certainly, an open procedure continues to have a high degree of safety and success.

Open CBDE in Patients With Repeated Diagnosis of CBD Stones and Previous Endoscopic or Surgical Clearence of Stones:

The laparoscopic management of a very dilated common duct, with special consideration as to the need of a biliary-enteric anastomosis, should be left for highly specialized surgeons and institutions.This situation requires an open procedure in the hands of the majority of surgeons.

References

1. Cuschieri A, Lezoche E, Morino M, et al. (1999) E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 13: 952-957

2. Guidelines for the clinical application of laparoscopic biliary tract surgery.Surg Endosc(2000) 14: 771-772

3. Park AE, Mastrangelo MJ (2000) Endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis. Surg. Endosc 14: 219-226

4. Moody FG (2000) Bile duct injury during laparoscopic cholecystectomy. Surg Endosc 14: 605-607

5. Bergamaschi R, Tuech JJ, Braconier L, et al (1999) Selective endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy for gallstones. Am J of Surg 178:46-49

9. The Role of ERCP in the Era of Laparoscopic Cholecystectomy

Jeffrey L. Ponsky, M.D.

Cleveland, Ohio

ERCP has been, and continues to be, an important resource in the approach to common bile duct stones. Its use in the preoperative assessment of patients with suspected stones is well established, yet, with surgeons becoming more adept at laparoscopic clearance of common duct stones, the use of preoperative ERCP has diminished somewhat. Indications for preoperative ERCP have included abnormal liver function tests, ultrasound evidence of a dilated common bile duct, gallstone pancreatitis, andjaundice. Surprisingly, abnormal liver function tests have been a poor predictor of common duct stones identified at preoperative ERCP. Dilation of the duct or a stone noted on ultrasound are better predictors, and jaundice should always prompt a preoperative ERCP, not only to identify stones, but to assure the absence of malignancy. While the success of common duct stone clearance by ERCP is high, the procedure carries its own morbidity and mortality which must be considered as additive to that of the laparoscopic cholecystectomy to follow.

Also expanding is the integrated use of Iaparoscopic techniques and ERCP. Some authors have described the use of intra-operative ERCP during the course of laparoscopic cholecystectomy. Significant complications have occurred in some of these cases. Others have recommended leaving a catheter in the cystic duct when stones are left in the common duct at cholecytectomy. In the post-operative period, a wire may be passed through the catheter, into the duodenum, to guide the sphincterotome at ERCP and ensure success of the stone removal. Alternatively, the wire may be passed into the duodenum at the time of lap chole, retrieved through the channel of the duodenoscope, and a wire guided papillatome used over the wire to correctly position the ampullary incision and remove stones. Another interesting and approach has been the use of the duodenoscope to simply guide a sphincterotomy performed antegrade at the time of laparoscopic cholecystectomy. In this situation, the duodenoscope is postitioned opposite the ampulla of Vater to observe, as the sphincterotome is advanced from the cystic duct, down the common duct, and into the duodenum. The incision is made under endoscopic guidance.

Certainly, ERCP has been an important modality in dealing with stones left in the common duct after laparoscopic cholecystectomy. When unexpected pain or jaundice occurs following cholecystectomy, ERCP should be performed to clarify the etiology and remove stones when they are identified. The success rate is in excess of 90%. The method also permits identification and occasionally treatment of bile duct injuries, leaks, or strictures. Clearly, the role of ERCP in the laparoscopic approach to common duct stones is still evolving and the applications are expanding. The general trend is to utilize ERCP less preoperatively, while expanding its role in the intraoperative and postoperative setting.

Selected Reading

1.Curet MJ,Pitcher DE, Martin DT, Zucker KA: Laparoscopic antegrade sphincterotomy. Ann Surg 221:149-55,1995.

2. Miller RE, Kimmelstiel FM, etal: Management of common bile duct stones in the era of laparoscopic cholecystectomy. Amen Surg 169:273-6,1995

3.Venu RP, Geenen JE: Overview of endoscopic sphincterotomy for common bile duct stone. in (ed) Kozarek RA, Endoscopic approach to biliary stones, Gastrointest EndoscClinicsofNorthAmerl(1): 3-26,1991.

Program Chairman	Bruce D. Schirmer, M.D.
Course Director	Joseph Petelin, M.D.
Lab Coordinator	Michael Brunt, M.D.
SAGES President	Nathaniel J. Soper, M.D.
SAGES Executive Director	Sallie Liesmann Matthews

SAGES 2001
Hands-On Course II

Treatment Modalities of CBD Stones
in the New Millennium

TABLE OF CONTENTS

L. William Traverso, M.D.

Douglas O. Olsen, M.D.,F.A.C.S.

Maurice Arregui, M.D.

George Berci, M.D.

Joseph B. Petelin, M.D., F.A.C.S.

Morris E. Franklin Jr., MD, FACS ; J. Arturo Almeida, MD

Richard M. Vazquez, M.D.

Luis E Burbano, MD

Jeffrey L. Ponsky, M.D.

L. William Traverso, M.D.

Douglas O. Olsen, M.D.,F.A.C.S.

Maurice Arregui, M.D.

George Berci, M.D.

Joseph B. Petelin, M.D., F.A.C.S.

Surgeon

Morris E. Franklin Jr., MD, FACS

J. Arturo Almeida, MD

Richard M. Vazquez, M.D.

Luis E Burbano, MD

Jeffrey L. Ponsky, M.D.

INDEX OF AUTHORS

Treatment Modalities of CBD Stones in the New Millennium

TABLE OF CONTENTS

L. William Traverso, M.D.

Douglas O. Olsen, M.D.,F.A.C.S.

Maurice Arregui, M.D.

George Berci, M.D.

Joseph B. Petelin, M.D., F.A.C.S.

Morris E. Franklin Jr., MD, FACS ; J. Arturo Almeida, MD

Richard M. Vazquez, M.D.

Luis E Burbano, MD

Jeffrey L. Ponsky, M.D.

L. William Traverso, M.D.

Douglas O. Olsen, M.D.,F.A.C.S.

Maurice Arregui, M.D.

George Berci, M.D.

Joseph B. Petelin, M.D., F.A.C.S.

Surgeon

Morris E. Franklin Jr., MD, FACS

J. Arturo Almeida, MD

Richard M. Vazquez, M.D.

Luis E Burbano, MD

Jeffrey L. Ponsky, M.D.

INDEX OF AUTHORS

SAGES 2001
Hands-On Course II

Treatment Modalities of CBD Stones
in the New Millennium