Laparoscopic Cholecystectomy with Common Bile Duct Exploration: Management of the impacted stone.

Russell Kirks, MD, Imran Siddiqui, MD, Erin Baker, Dionisios Vrochides, MD, PhD, John Martinie, MD, David Iannitti, MD, Ryan Swan, MD. Carolinas Medical Center, Department of General Surgery, Section of Hepatobiliary and Pancreatic Surgery

Choledocholithiasis complicates 3-11% of cases of cholelithiasis, and can be suggested based on preoperative labs or intraoperative cholangiogram. Endoscopic, percutaneous, and surgical bile duct clearance strategies are available. For smaller mobile stones, laparoscopic trans-cystic ductal clearance can be accomplished during cholecystectomy with balloon-tipped catheters, choledochoscopy and basket retrieval, or with flushing and the administration of medications to relax the Sphincter of Oddi. In the case of large impacted gallstones and certainly stones that have failed endoscopic or percutaneous interventions for extraction, open CBDE is more often required. However, with improvement in laparoscopic techniques, laparoscopic CBDE is also feasible in these settings, thus avoiding the morbidity of an upper abdominal laparotomy incision.

In the presented video, a patient with a 2cm impacted and obstructing common bile duct stone is referred for surgical ductal clearance after two endoscopic procedures were unable to remove the stone. Prior to surgery, silastic indwelling biliary stents are placed for biliary decompression. The patient was found to have severe acute on chronic inflammation. Laparoscopic cholecystectomy is performed. Intraoperative ultrasound assists with definition of ductal and vascular anatomy in a chronically-inflamed field. A generous longitudinal cholodochotomy is performed and the stone is extracted with gentle caudal pressure on the duct. The biliary stents are left in place and the choledochotomy is closed with a running barbed, self-locking absorbable suture. The patient was discharged home on post-operative day number 2. Subsequent ERCP with stent removal revealed no stricture or leak.

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