Laparoscopic Common Bile Duct Exploration
Choledocholithiasis can be treated by either open, laparoscopic, percutaneous, or endoscopic means (Endoscopic Retrograde Cholangiopancreatography [ERCP]). In experienced hands, the laparoscopic common bile duct exploration is a potential option for managing stones within the biliary tree at the same time as laparoscopic cholecystectomy.
Patients should be given prophyaxis for deep venous thrombosis (subcutaneous heparin or low-molecular-weight heparin perioperatively, as well as sequential compression devices intraoperatively) and prophylactic antibiotics, usually or first generation cephalosporin.
The procedure is performed with the patient in the supine position, with the surgeon on the patient’s right and the assistant on the left. Care must be taken to assure that the operating bed is positioned such that a fluoroscopic C-arm can be positioned for imaging in the patient’s right upper quadrant. Incorrect bed position can result in significant intraoperative delays and unnecessary risk to the patient when re-maneuvering the bed is required.
Normally, the laparoscopic monitors are placed at the patient’s head to the left and right. All equipment, including equipment necessary for common bile duct exploration and an open surgical tray on stand-by, should be confirmed prior to the patient being brought into the room.
Port placement can be identical to that for laparoscopic cholecystectomy, whether or not cholecystectomy is being performed at the same time. A 10-12 mm infra-umbilical trocar is initially placed with either an open cut-down technique, optical trocar, pre-insufflation with a Veress needle followed by trocar placedment or optical trocar placement. A 5 or 10/12 mm port is placed inferior to the xyphoid process under direct camera-visualization, to the right of the falciform ligament, and two 5 mm placed inferior to the right subcostal margin in the anterior axillary line and in the midclavicular line. Care should be taken not to injure the superior epigastric vessles when placing the midclavicular port.
Cholangiogram and common bile duct exploration
There are two different approaches to performing laparoscopic common bile duct exploration: transcystic and through a choledochotomy.
The cystic duct is exposed for 2-3 cm and scissors used to incise it. A cholangiogram catheter is then introduced. If it has a balloon tip, this can be inflated, and 50% contrast injected under fluoroscopy to confirm position and anatomy. The common bile duct can be flushed with 30 cc of saline via the catheter. Small stones may be flushed this way, especially with administration of 1 mg of glucagon to allow relaxation of the Sphinctor of Oddi. If flushing is inadequate to clear any small stones, fluoroscopic-guided basket retrieval can be performed, or a 4 Fr Fogarty balloon can be inserted through the cystic duct, inflated, and withdrawn to pull stones into the intra-abdominal cavity to be retrieved. Alternatively, or for more difficult stones, the cystic duct orifice can be dilated in preparation for choledochoscopy. A guide wire is first passed into the common duct transcystically and an 8 Fr angioplasty balloon used to dilate the orifice. A 12 Fr introducer catheter is placed for repeated passage of the choledochoscope.
Through the choledochoscope a retrieval basket can be inserted under direct visualization. Laser ablation of stones has also been described. In either case, pressurized saline through a side working port of the scope facilitates clearance of small stones and particulate matter.
Alternatively, the above methods can be performed through a choledochotomy. The common bile duct is exposed and a vertical ductomy performed for about 5 mm on the anterior surface of the duct, distal to the cystic-common bile duct junction. The techniques for stone clearance are identical to the trans-cystic approach. The choledochotomy can be managed with a T-tube which is sutured in place with absorbable suture, primary closure over a stent (for later removal by ERCP), or primary closure alone.
If a T-tube was placed, removal can occur 4 weeks postoperatively when the tract to the skin is epithelialized. Usually, a cholangiogram is performed through the T-tube first to assure adequate clearance of the ductal system. When the transcystic approach is used, no special care is required other than routine postoperative care.