Laparoscopic management of Dormia basket impaction

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摘要

This video presents the endoscopic and surgical management of a Dormia basket impaction in the common bile duct. The patient has acute cholangitis associated with cholelithiasis.

分類

complex cases

關鍵字

laparoscopy, management, Dormia basket impaction, biliary tract

媒體類型

期間

11'00''

刊物

2008-09

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Sept 2008;8(09).
URL: http://www.websurg.com/doi-vd01en1910.htm

Laparoscopic management of Dormia basket impaction

1. Clinical case presentation 00'21''

This video demonstrates the case of a patient presenting with acute cholangitis associated with cholelithiasis. The presence of Mirizzi’s syndrome was suspected.

2. Dormia basket endoscopic extraction 00'38''

We first perform an endoscopic extraction of the common bile duct stone using the lithotripter that has the disadvantage of leaving the Dormia basket in place. One can see here the Dormia basket impacted at duodenal level. We decide to extract it endoscopically. To do so, we perform an endoscopic sphincterotomy, which will allow us to retrieve the Dormia basket. We can observe the position of the endoscope and the lithotripter superiorly. We perform a cholangiogram and examine the dilated common bile duct. We identify the presence of a stone located in the inferior portion of the common bile duct. Endoscopic extraction of the Dormia basket turns out to be technically impossible due to its position and the common bile duct was not yet drained. A plastic stent should then be placed. The 1st stent achieves drainage of the common bile duct on the right side, and we place a 2nd plastic stent, which will ensure drainage of the common bile duct on the left side. The plastic stent to the right has migrated caudally and we will use a Dormia basket to facilitate its correct positioning. Once this plastic stent has been correctly positioned, we perform a radiological control, which demonstrates the good positioning of the stent as well as the endoscopic drainage of the common bile duct.

3. Dormia basket laparoscopic extraction 02'35''

Since it is impossible to retrieve the Dormia basket endoscopically, and using the correct drainage of the common bile duct, we decide to carry out its extraction laparoscopically.

4. Laparoscopic cholecystectomy 02'46''

First, we perform a cholecystectomy. We free the perivesicular adhesions. The gallbladder is acutely inflamed, which demonstrates the acute stage of the pathology. We take down the adhesions using monopolar cautery, and scissors in this case.The cholecystectomy is performed in a standard fashion by freeing of the anterior peritoneum. We can see the presence of a perivesicular abscess, which will be partially aspirated. Caudal traction is exerted on the gallbladder and we continue the dissection of the posterior peritoneum in order to open Calot’s triangle. Once Calot’s triangle has been identified and then partially opened, we try to skeletonize and isolate it. We place a plastic bag in order to avoid any bile leak. Dissection is still continued at the level of Calot’s triangle. We have slightly injured the cystic artery laterally here. This will be controlled using endoclips. Then a posterior division will be carried out. We try to dissect the cystic duct as much as possible. To do so, we use a hook. We then place an endoclip proximally and then carry out partial division in order to perform a transcystic cholangiography, which turns out to be impossible. Therefore, we decide to perform a choledochotomy.

5. Laparoscopic choledochotomy 04'42''

The choledochotomy is performed using the cold blade of a scalpel. The incision is about 1cm long, and it will help to partially evacuate the bile under pressure. This maneuver, with the help of an atraumatic forceps, helps to extract the 2 plastic stents that were previously placed endoscopically.

6. Dormia basket extraction (through the common bile duct) 05'21''

Once this extraction is complete, we perform an intraoperative cholangiography, which aims to control the patency and vacuity of the common bile duct and extract the incarcerated Dormia basket. We then place a balloon in order to extract the Dormia basket. This maneuver is difficult to perform. Unfortunately with this instrument, it is impossible to perform the extraction due to the impaction of the basket. We think that a part of the basket is located at duodenal level, which makes the extraction difficult to perform. We then decide to extract it by introducing another Dormia basket to catch the former one. After several attempts, we manage to catch one arm of the basket. We believe we have caught the free extremity of the basket. Once this is caught, we use the laparoscopic choledochoscope to perform the extraction of the Dormia basket. This is difficult to perform but we do it atraumatically not to injure the common bile duct. Once this is removed from the common bile duct, we then extract it using a laparoscopic forceps at the level of the abdominal cavity. A new intraoperative cholangiography is performed to check the vacuity of the common bile duct and rule out the presence of residual stone.

7. Kehr drain placement 07'30''

A Kehr drain is placed in the common bile duct region. We first place the inferior arm and then the superior arm, and then we close the choledochotomy using interrupted sutures. Generally, Vicryl sutures 4/0 are used. In the present case, we place 3 stitches of Vicryl 3/0. Intraoperative cholangiography is then performed to control the good positioning of the Kehr drain as well as the patency and vacuity of the common bile duct.

8. Completion of cholecystectomy 08'14''

We complete the cholecystectomy and dissection is carried out using monopolar cautery. Counter-traction is exerted at the level of the gallbladder and we retract the liver in a blunt fashion. We open the gallbladder like opening the pages of a book.

9. Specimen extraction 08'40''

We then place the gallbladder specimen into a plastic extraction bag. We control hemostasis and extract the gallbladder.

10. Drainage placement 08'53''

Surgical drainage of the liver bed is undertaken using two blades.

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