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Laparoscopic common bile duct exploration: choledochotomy approach
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摘要
The description of the laparoscopic common bile duct exploration: choledochotomy approach covers all aspects of the surgical procedure used for the management of common bile duct stones.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration and exposure, dissection, intraoperative cholangiography, laparoscopic ultrasonography, choledochotomy, stone extraction, common bile duct closure.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration and exposure, dissection, intraoperative cholangiography, laparoscopic ultrasonography, choledochotomy, stone extraction, common bile duct closure.
Consequently, this operating technique is well standardized for the management of this condition.
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媒體類型
 刊物
2003-09
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普通的
最愛
 音訊
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數位出版
WeBSurg.com, Sept 2003;3(09).
URL: http://www.websurg.com/doi-ot02en013a.htm
URL: http://www.websurg.com/doi-ot02en013a.htm
Laparoscopic common bile duct exploration: choledochotomy approach
1. Introduction
Since the original description by Courvoisier of common bile duct (CBD) surgery in 1889 (Courvoisier, 1890), this field has changed dramatically. Introduction of laparoscopic cholecystectomy in 1989 (Berthou et al., 1997; Dubois et al., 1989) has accelerated these changes, and as a logical extension to this the next step was the exploration of the CBD. Several reports from experienced groups have demonstrated the efficacy, safety and cost-effectiveness of laparoscopic techniques to deal with CBD stones (Cuschieri et al., 1996; Cuschieri et al., 1999; Tranter and Thompson, 2002; Vecchio and MacFadyen, 2002). Two laparoscopic techniques to clear the common bile duct of stones exist. These are the transcystic and the choledochotomy approaches. Laparoscopic exploration is widely used in different centers across the world, but has not yet become standard treatment. These techniques enable appropriate patients to undergo complete management of their biliary tract disease with one invasive procedure. A frequently used alternative to surgery for choledocholithiasis is endoscopic retrograde cholangio-pancreatography (ERCP). This technique is extensively used, but carries a risk of pancreatitis, hemorrhage and duodenal perforation. In addition to this, there is the increased cost of patient management since these patients will have required surgical intervention (cholecystectomy), before or after the ERCP.
Once choledocholithiasis is confirmed by intraoperative cholangiogram or ultrasound, the surgical decision will depend upon the location, number and size of stones, anatomy, equipment, and surgeon expertise and preference. If a decision is made to proceed with the transcystic approach, the cystic duct will need to be incised and possibly dilated before the stones can be removed by one of a number of options. Confirmation of stone clearance is necessary once the procedure is completed. If this procedure is unsuccessful, one can proceed with other options such as CBD exploration, open surgery or postoperative ERCP.
In a review by Vecchio and MacFadyen (2002), the most common laparoscopic approach for common bile duct stones was the transcystic approach.
Note: sections 1 to 11 are identical for all chapters on laparoscopic bile duct exploration.
In memoriam of B Malassagne who drafted the first version of this chapter.
2. Biliary anatomy
• Common bile duct
The right and left hepatic ducts collect bile from the liver; they merge to form the hepatic duct, which passes downward in the free edge of the lesser omentum, where it is usually joined at an acute angle by the cystic duct, to form the common bile duct (CBD). It passes behind the superior portion of the duodenum, in front of the portal vein, and to the right of the hepatic artery; it then runs in a groove near the right border of the posterior surface of the head of the pancreas. It usually unites with the pancreatic duct and opens into the duodenum by a common orifice at the ampulla of Vater (major duodenal papilla).1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Variations/extrahepatic ducts 1
• Principles
A sound, working knowledge of the anatomic variations will facilitate intraoperative identification of the various ductal structures. Complete identification of the structures of Calot’s triangle before any duct is opened or divided is mandatory to safeguard against potentially serious complications of this surgical procedure.• Variation 1
Cystic duct insertion of the right lateral (posterior) segment• Variation 2
Duct of Luschka• Variation 3
Duct of Luschka• Variation 4
Direct drainage into the gallbladder of the right lateral (posterior) segments and right paramedian (anterior) segments• Variations/extrahepatic ducts 2
• Variation 5
Gallbladder insertion of accessory right hepatic duct• Variation 6
Congenital absence of a cystic duct• Variation 7
Low union with common hepatic duct• Cystic duct
The cystic duct is around 4 cm long, runs downward and medially to join the hepatic duct to form the common bile duct. The mucous membrane lining its interior is thrown into a series of crescentic folds, from five to twelve in number (cystic valves). The cystic duct usually enters the common bile duct at an acute angle. However, the cystic duct may run parallel to the common hepatic duct for a variable distance before joining it on its right side or pass anterior or posterior to the common hepatic duct before joining it on its left side. In addition, the cystic duct may join either the right hepatic duct or a segmental branch of the right hepatic duct. An accessory hepatic duct or cholecystohepatic duct (duct of Luschka) may also enter the gallbladder through the gallbladder fossa and if encountered during a cholecystectomy should be ligated to prevent a biliary fistula.
• Abnormal junctions/cystic duct
• Variation 1
Anterior crossing, left insertion• Variation 2
Posterior crossing, left insertion• Variation 3
Lower insertion3. Vascular anatomy
• Hepatic artery
From the celiac trunk, the common hepatic artery passes anteriorly and to the right, to the upper margin of the first part of the duodenum, forming the lower boundary of the foramen of Winslow. It then crosses the portal vein anteriorly and ascends between the layers of the lesser omentum to the porta hepatis as the hepatic artery. Here it divides into two branches, right and left hepatic arteries, which each supply the corresponding lobe of the liver. The hepatic artery, in its course along the free edge of the lesser omentum, is in relation with the common bile duct and portal vein, with the duct lying to the lateral to the artery, and the vein behind (portal triad). The left hepatic artery may have its origin from the left gastric artery in about 15-20% of the patients. The right hepatic artery may originate from the superior mesenteric artery in up to 20% of cases.1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Cystic artery
The cystic artery is usually a branch of the right hepatic but may also originate from the left hepatic, common hepatic, gastroduodenal, or superior mesenteric arteries. The cystic artery is usually located within the borders of Calot’s triangle (hepatic duct, cystic and lower border of liver). It usually enters this space by passing from behind the hepatic duct but there are a number of variations. The cystic artery divides into anterior and posterior branches before entering the gallbladder. 1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Variations/cystic artery
• Variation 1
Double cystic artery; one posterior-inferior and one anterior-superior to the cystic duct• Variation 2
Double cystic artery; both superior to the cystic duct high in Calot’s triangle• Variation 3
Cystic artery originating from the proper hepatic artery• Variation 4
Cystic artery originating from a normal left hepatic artery, high in Calot’s triangle• Variation 5
Cystic artery originating from the celiac trunk, anterior-superior to the cystic duct• Biliary tract blood supply
The blood supply to the extrahepatic biliary tract originates distally from the gastroduodenal, retroduodenal, and posterior superior pancreaticoduodenal arteries and proximally from the right hepatic and cystic arteries. These arteries supply the common bile duct and common hepatic duct through branches that usually run parallel to the duct in the 3 and the 9 o\'clock positions.1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Portal vein
The portal vein is about 8 cm long, and is formed at the level of the second lumbar vertebra in front of the inferior vena cava and behind the neck of the pancreas by the union of the superior mesenteric and splenic veins. It ascends in the free edge of the lesser omentum behind the biliary tract and hepatic artery. It divides into a right and a left branch, which accompany the corresponding branches of the hepatic artery into the substance of the liver. It is accompanied by a rich lymphatic plexus. The right branch of the portal vein enters the right lobe of the liver, but before doing so it generally receives the cystic vein.1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
4. Choice/technique
Different groups have reported success with both the transcystic, and the choledochotomy techniques. The following table (adapted from Cameron, 2001) gives appropriate indications for the two techniques. For those surgeons with significant laparoscopic experience, some of the contraindications may be relative. TA = Transcystic Approach
Ch = Choledochotomy
* to insertion of cystic duct
NR = Not Recommended
5. Operating room set-up
• European technique
• Patient
The patient is positioned:- supine;
- with the left arm placed at 90°;
- the right arm alongside the body;
- the legs apart;
- reverse Trendelenburg.
• Team
1. The surgeon stands between the patient’s legs.2. The first assistant is on the patient’s left side.
3. The second assistant’s position varies depending on the team’s preferences, most often to the patient’s right, facing the first assistant.
• Equipment
1. Radiological equipment (portable X-ray unit or portable C-arm fluoroscope, laparoscopic ultrasound)2. Laparoscopic unit
3. Anesthetic unit
4. Laparoscopic unit for choledochoscopy
5. Instrument table
6. Electrocautery
7. Operating table
• American technique
• Patient
The patient is positioned:- supine;
- with the left arm placed at 90°;
- the right arm alongside the body;
- the legs together;
- reverse Trendelenburg;
- lateral tilt to patient’s left.
• Team
The surgeon operates from the left side of the patient with the camera person by his side and the assistant and scrub nurse on the other side of the operating table.1. The surgeon is on the patient’s left side.
2. The first assistant is on the patient’s right side, facing the surgeon.
3. The second assistant is on the patient’s left side, next to the surgeon.
• Equipment
1. Radiological equipment (portable X-ray unit or portable C-arm fluoroscope, laparoscopic ultrasound)2. Laparoscopic unit
3. Anesthetic unit
4. Laparoscopic unit for choledochoscopy
5. Instrument table
6. Electrocautery
7. Operating table
6. Trocar placement
• European technique
• Principles
In addition to the 4 trocars usually used for cholecystectomies, a fifth trocar (large enough for the choledochoscope) may be required. It is placed in the right subcostal area in the axis of the cystic duct, halfway between the xiphoid and the right subcostal trocars. • Optical
The optical trocar is positioned in the umbilical area. In our practice, we use a degree scope, but a 30 degree one may sometimes be useful.• Operating
The operating trocars are positioned in the right and left hypochondrium. The graspers, scissors, hook, clip applier or dissection devices are introduced through these trocars.• Retractor
The retractor trocar is positioned in the epigastric area. In addition to the retracting instruments, a suction-irrigation device can also be introduced through this trocar.• Choledochoscopy
A fifth trocar may be introduced if needed to perform choledochoscopy. To avoid damaging the choledochoscope, a trocar with no valve or a retractable valve is ideal. This trocar must be long enough to allow the tip of the choledochoscope to enter the cystic duct lumen without having to handle it with a grasper.• American technique
• Principles
Trocars are placed in a similar fashion to laparoscopic cholecystectomy by American technique. Four trocars are commonly used. A fifth trocar may be placed just over the area of the gallbladder for introduction of instrumentation or the choledochoscope into the cystic duct.• Optical
The optical trocar is positioned in the umbilical area. In our practice, we use a 0 degree scope, but a 30 degree one may sometimes be useful.• Operating
The operating trocars are positioned in the epigastrium and right subcostal area on the mid-clavicular line. The graspers, scissors, hook, clip applier or dissection devices are introduced through these trocars.• Retractor
The retractor trocar is positioned in the right subcostal area on the anterior axillary line. • Choledochoscopy
A fifth trocar may be introduced if needed to perform cholangioscopy. To avoid damaging the choledochoscope, a trocar with no valve or a retractable valve is ideal. This trocar must be long enough to allow the tip of the choledochoscope to enter the cystic duct lumen without having to handle it with a grasper.7. Instrumentation
• Choledochoscope
The choledochoscope used in the choledochotomy approach has a small outer caliber (<= 3.2 mm). The dimensions of the operating channel must be >= 1.1 mm (in order to be able to introduce a Dormia basket while maintaining the irrigation flow). The choledochoscope should have a maneuverable tip, but with a certain degree of rigidity.• Ultrasound
Ultrasound has been used successfully in open surgery for many years. Since the introduction of laparoscopic ultrasound probes, this technology has also been used for evaluation of abdominal pathology during minimally invasive procedures. With the loss of touch and stereoscopic vision during laparoscopy, such technologies become an important source of additional information. Ultrasound can be used for evaluation of the biliary anatomy and to evaluate the presence of stones. Several probes with or without flexible tips and with different degrees of motion are available on the market.• Extraction devices
The Dormia baskets used must be of small caliber (<=1 mm) to allow for irrigation of the CBD during manipulation. Since the operating channel of the choledochoscope measures 1.1 mm, it is ideal to use 0.8 mm Dormia baskets although the Dormia basket can be passed alongside the scope (see video).1. Dormia basket
2. Suction-irrigation device
3. Atraumatic grasper
• Dilators
Semi-rigid dilators are used:- bougies or flexible atraumatic dilators;
- sequential bougie catheters;
- balloon dilatation catheters – these can also be used to extract stones.
• Drains
A transcystic drain can be left in situ where there is concern about postoperative CBD obstruction from inflammation, edema or retained stones as a “safety valve”. It can also be used postoperatively for imaging.8. Exploration and exposure
• Exposure/right subhepatic area
• Principles
Routine abdominal exploration is carried out after introduction of the laparoscope. Once done, we focus our attention to the biliary tree and gallbladder. An initial important step in bile duct surgery is adequate exposure of the subhepatic area. Techniques that may aid with this task include:• Suspension of the liver
The liver is lifted by suspension of the ligamentum teres with the aid of a transcutaneous suture. • Gravity
The patient is placed in steep reverse Trendelenburg position with a slight tilt to the left, facilitating the descent of the organs towards the pelvis and left side.• Retraction
The duodenum is retracted caudally with the use of a retractor. The gallbladder infundibulum is retracted upward and laterally.• Exposure of Calot’s triangle
To ensure safe dissection, perfect exposure of the anterior surface of Calot’s triangle is essential. Once any adhesions to the gallbladder are freed, Calot’s triangle is stretched open by retracting the fundus of the gallbladder superiorly and stretching the cystic duct laterally (to the right) by retracting laterally on the infundibulum of the gallbladder (Hartman’s pouch). This principle of exposure is used in both the European and American techniques but the ports used for retraction differ.9. Dissection
• Dissection of Calot’s triangle
The aim of this step is to isolate the biliary and vascular elements constituting Calot’s triangle.The dissection is begun in close proximity of the gallbladder, at the junction between the infundibulum and the cystic duct.
The peritoneum covering the neck of the gallbladder is incised posteriorly and anteriorly.
At this point, skeletalization of the elements of the cystic pedicle is performed. The cystic duct, and the cystic artery respectively, are fully exposed (for greater detail see chapter on laparoscopic cholecystectomy).
• Clip application
After identifying the cystic artery and cystic duct, the artery is clipped proximally and distally. The cystic duct is then clipped close to its junction with the gallbladder. If indicated, transcystic cholangiography or laparoscopic ultrasound follows to evaluate the local anatomy and the presence of stones. 10. Intraoperative cholangiography
• Goals
- to assess the anatomy of the biliary tract (anatomic variations and size of the CBD);- to determine the location, size and number of the calculi.
Static simple X-rays have been used in the past to assess the biliary tract but are inferior to dynamic fluoroscopy, which allows real-time assessment of the biliary tract anatomy. Fluoroscopy has been demonstrated to be faster to perform and more accurate than static IOC (Jones et al., 1995; Berci, 1995).
• Technique
• Cystic duct incision
The cystic duct is partially transected on its anterior surface 1 cm from the junction with the CBD. This location is chosen in order to avoid problems in inserting the cholangiocatheter due to valvulae or plications of the cystic duct. It also facilitates easy closure of the cystic duct stump without risk of injury to the CBD. Thus the cystic duct junction with the CBD must be identified. It is important not to fully transect the cystic duct as traction on the gallbladder helps to keep the duct well exposed.• Position/OP table
The operating table is placed into a flat position (i.e. taken out of reverse Trendelenburg and left tilt) with a slight right tilt to displace the CBD anteriorly.• Catheter introduction
The cholangiocatheter is brought to the incision of the cystic duct using a rigid introducer, either percutaneously or through the right subcostal trocar (there are also soft catheters and special cystic clamps that can also be used for cholangiography). The probe is inserted 1 to 3 cm and held in place with a clip or a grasper. We recommend using a rigid tip probe for this part of the procedure to avoid occlusion of the probe by the clip.
• Contrast injection
Cholangiography is performed in three steps:1. A few milliliters of diluted contrast (50% dilution) are injected into the bile ducts under radiographic guidance. It is essential to ensure that no air bubbles are in the injection set because air bubbles in the CBD can be confused with stones. If static pictures are being taken the first is taken now to detect stones in the CBD.
2. The dye injection is continued until a complete cholangiogram is obtained. The Trendelenburg position may facilitate the opacification of the intrahepatic bile ducts. A second static picture is taken at this point.
3. The passage of dye into the duodenum under low pressure should be confirmed by a third radiograph.
If there is inadequate visualization of the entire common bile duct during cholangiography, gentle pressure can be placed with an instrument over the distal part of the CBD to encourage adequate filling and delineation. If fluoroscopy is being used then images can be obtained dynamically while injecting contrast.
• Catheter removal
The cholangiocatheter is removed once the cholangiogram is finished, and if no stones are found the cystic duct is closed and a completion cholecystectomy performed.The presence of stones in the CBD is suspected when the radiograph demonstrates:
- radiolucent defect(s);
- a crescent-shaped blockage of the contrast;
- dilatation of the bile ducts;
- the absence of passage of the contrast into the duodenum.
The choice to perform a choledochotomy rather than a transcystic approach will depend upon the precise findings (see indications/contraindications).
11. Laparoscopic ultrasonography
Ultrasound (US) examination of the bile duct during cholecystectomy compares well with operative cholangiography. Tranter and Thompson (2003) describe their results on intraoperative ultrasound versus intraoperative cholangiography (IOC). US demonstrated the biliary tree better than intraoperative cholangiography, and proved to be more sensitive and specific in the diagnosis of bile duct stones.The use of intraoperative ultrasonography (IOUS) also saves the patient from ionizing radiation, and may be possible where IOC has failed. It does however require special skills of interpretation in which few surgeons have been trained (Thompson et al., 1998; Falcone et al., 1999).
12. Choledochotomy
• Principles
After opening the anterior peritoneal layer along the free edge of the lesser omentum, hemostasis is achieved and the anterior surface of the CBD is exposed over a length of 10 to 20 mm. The choledochotomy (made either vertically or transversally) must be long enough to allow for the insertion of a 5 mm choledochoscope, and for the extraction of the stones, without tearing the CBD. Risks are a posterior injury of the CBD and too short an incision leading to tearing of the CBD during stone extraction or choledochoscope manipulation.
• Longitudinal
The choledochotomy is made vertically in the supra-duodenal portion of the CBD with a retractable blade or scissors. It can be enlarged if necessary. It should be equivalent in length to the size of the largest stone. It can be used for any CBD measuring over 7 mm in diameter.• Transverse
A transverse incision is rarely used in laparoscopy. However, it may be considered in cases of a very dilated CBD/or when a biliary drainage procedure such as a bilio-enteric anastomosis is being considered.13. Stone extraction
• Objective
The goal is to completely clear the biliary tract, while avoiding bile duct injuries and contamination of the abdominal cavity. To prevent stones from escaping into the abdominal cavity, a gauze pad is introduced behind the free edge of lesser omentum and below the neck of the gallbladder. An endoscopic extraction bag is positioned adjacent to the CBD into which each stone is placed as it is extracted. Commonly, stones are expelled spontaneously when the CBD is opened. Residual stones are extracted using various techniques.• Blind extraction
• Spontaneous clearance
Commonly, stones clear spontaneously when the CBD is opened. Residual stones are extracted using various techniques.• With a suction-irrigation device
A high-pressure suction-irrigation device makes it possible to flush out a large number of stones via opening of the CBD when the choledochoscope is removed.• With a grasper
Stones that are easily accessible or visible through choledochotomy are extracted with atraumatic graspers. Stones can also be pushed out by exerting pressure with the graspers on the surrounding CBD wall.• With a Fogarty catheter
The catheter is passed into the CBD and beyond the stone. It is then inflated to occlude the lumen and gently withdrawn bringing any stone up into the choledochotomy. It can be useful to dislodge impacted stones. • With a Dormia basket
The basket is introduced into the choledochotomy. It is then opened and the basket is moved around slowly until the stone can be felt and pushed into the basket prior to closure and extraction.• Extraction under visual guidance
• With fluoroscopy
The Dormia basket is introduced into the CBD under fluoroscopic guidance. Stone entrapment and extraction can also be visualized fluoroscopically. • With choledochoscopy
Stone extraction under endoscopic guidance includes the following steps:- introduction of the choledochoscope and visualization of the stone (s);
- introduction of the Dormia basket into the CBD through the operating channel (or alongside the choledochoscope). The stone is retrieved by the Dormia basket and securely held against the tip of the endoscope.
The choledochoscope is withdrawn with the Dormia basket under continual view.
• Confirming stone clearance
It is important to confirm that the CBD has been completely cleared. This may be done either endoscopically or radiographically although endoscopic exploration is more accurate. The biliary tree should be visualized from the papilla up to the first or second biliary division of the right and left hepatic ducts.14. CBD closure
• Simple CBD closure
Primary closure of the choledochotomy may be performed longitudinally using an absorbable 5.0 or 6.0 suture without a drain. However, when there is risk of ongoing obstruction due to the presence of edema, inflammation or retained stones then a drain should be placed.Good results have been described by Decker et al. (2003) in a multicenter study of over 100 choledochotomies with primary closure of the common bile duct. An intraoperative cholangiogram confirming free flow of bile into the duodenum is essential to the safety of a primary closure. One of the risks inherent to this technique is possible stenosis of the CBD.
• Closure over a transcystic drain
Where doubt remains about CBD clearance or in case of an inflammatory papilla, a transcystic or an antegrade drain may be left in place after the primary closure of the choledochotomy. This acts to prevent the build-up of pressure in the biliary tract should there be distal obstruction. The drain is attached to the cystic duct stump with an absorbable ligature. Wu and Soper (2002) studied different ways to close the choledochotomy in an animal model and concluded that laparoscopic antegrade CBD stenting with primary closure of the choledochotomy is the preferred technique as it produces fewer stenoses.• Closure over a T-tube drain
After placing a T-tube drain in the CBD, the long limb of the T-tube is brought out through the lower end of the choledochotomy. The choledochotomy is then closed around the drain with interrupted or continuous 5.0 absorbable sutures. Injection of the repaired CBD with methylene blue makes it possible to check for leakage of the suture line. The T-tube provides easy access postoperatively for imaging.• Cholecystectomy
After closure of the cystic duct a retrograde cholecystectomy is performed, as described in the cholecystectomy chapter. It is probably better to perform cholecystectomy without division of the cystic duct to keep a good exposure of the CBD prior placement of T-tube or transcystic drain to avoid its displacement during cholecystectomy.15. Postop period
In the absence of biliary drainage:Oral intake is restarted postoperatively as soon as the patient recovers form anesthesia and advance as tolerated.
Patients stay at least overnight for observation. If no drain was placed during surgery and they are doing well, they are discharged the next day.
In the presence of biliary drainage:
Oral intake is restarted postoperatively as soon as the patient recovers form anesthesia and advance as tolerated.
Cholangiography is performed on the first or second postoperative day. If follow-up is normal, the transcystic drain or T-tube is clamped and removed after no less than 10 days. Patients are instructed on drain care. In case of poor drainage into the duodenum without residual stones, the drain is left open for 10 to 15 days. Another cholangiography is then done before removal.
For residual stone(s), the drain is left open until, either, there is spontaneous clearance of the CBD (50% of cases) or until an endoscopic sphincterotomy can be performed.
Complications
The morbidity of laparoscopic common bile duct exploration (LCBDE) ranges between 0 and 29.1%. Bile leak is the most common complication after LCBDE and accounts for 40% of all complications (Vecchio and MacFadyen, 2002). Although re-operation or ERCP is required in some cases, most leaks are self-limiting and can be treated successfully by percutaneous drainage.
The most worrying complications related to the transcystic approach is CBD injury and it is essential that such injuries are identified immediately as late presentation is associated with poorer outcome.
16. Conclusions
Common bile duct exploration in conjunction with laparoscopic cholecystectomy will clear the CBD in the majority of patients, reducing the hospital stay and any subsequent endoscopic procedures. Franklin reported being able to clear the CBD of stones in over 94% of cases using the choledochotomy approach (Dorman et al., 1998). However, some surgeons perform a laparoscopic choledochotomy only when the transcystic approach has failed. This is often the case when stones are located in the proximal common bile duct, there is acute angulation of the cystic duct-CBD junction, there are cystic valves or tortuosity of the cystic duct, there is a low or abnormal insertion of the cystic duct into the CBD, or there are CBD stones larger than 6-7 mm in diameter. In experienced hands laparoscopic common bile duct exploration is a cost-effective and perhaps the safest method for the treatment of common bile duct stones. 17. Reference
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