Laparoscopic management of duodenal perforation during endoscopic sphincterotomy for CBD gallstone

Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is commonly used in the treatment of common bile duct stones. It is widely regarded as a safe procedure, but the major complication rate approaches 10%. ERCP-related perforations occur in about 1% of patients. The objective of this film is to demonstrate how to perform the exploration of the abdominal cavity in relation to a duodenal perforation following an endoscopic retrograde common bile duct exploration because of suspected stone migration.

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Laparoscopic management of duodenal perforation during endoscopic sphincterotomy for CBD gallstone

Authors

J Leroy, Gf Donatelli, S Paveliu, J Marescaux

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is commonly used in the treatment of common bile duct stones. It is widely regarded as a safe procedure, but the major complication rate approaches 10%. ERCP-related perforations occur in about 1% of patients. The objective of this film is to demonstrate how to perform the exploration of the abdominal cavity in relation to a duodenal perforation following an endoscopic retrograde common bile duct exploration because of suspected stone migration.

Catégorie

clinical cases

Mots-clés

Laparoscopic management, duodenal perforation, endoscopic sphincterotomy, CBD gallstone

Type de vidéo

Vidéo chirurgicale

Durée

05'18''

Publication

2010-11

Popularité

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Sous-titres

E-publication

WeBSurg.com, Nov 2010;10(11).
URL: http://www.websurg.com/doi-vd01en3049.htm

Laparoscopic management of duodenal perforation during endoscopic sphincterotomy for CBD gallstone

1. Introduction 00'30''

The objective of this film is to demonstrate how to perform the exploration of the abdominal cavity in relation to a duodenal perforation following an endoscopic retrograde common bile duct exploration because of suspected stone migration.

2. Finding of peritoneal bilious effusion 00'54''

As soon as the abdominal cavity is accessed, a peritoneal bilious effusion is found, notably in the subhepatic region, where a few adhesions are present —they are easily taken down.

3. Common bile duct exploration 01'14''

Before carrying on the surgical procedure, a common bile duct exploration is undertaken. This was not possible using the retrograde approach due to the perforation situated at the first portion of the duodenum.

4. Cholangiography 01'32''

To do so, the cystic duct is isolated and clipped in its proximal part. A cholangiography catheter is then introduced into the distal portion of the cystic duct. Air tightness is ensured in order to perform a cholangiography. It allows to rule out the presence of intrahepatic bile duct dilatation. After a slight delay to evacuate, the contrast liquid passed adequately into the duodenum without any stenosis and without any signs of visible lithiasis. In case there is a small lithiasis, it will not necessitate any surgical approach.

5. Duodenal mobilization 02'31''

The procedure is carried on with the mobilization of the first duodenum and of the genu superius in order to view all aspects —anterior, lateral, superior and posterior— of the duodenal flexure and of the first duodenum.

6. Identification and suture of the perforation 02'54''

As a result, the perforation can be well visualized. An interrupted suture of monofilament Maxon material can be performed. The separate stitches are placed extramucosally. This will be achieved without any particular difficulty thanks to the perfect duodenal mobilization. The knots are tied intracorporeally in a conventional fashion. Several stitches will be necessary to ensure a perfect air tightness of the perforated area.

7. Cholecystectomy 03'53''

Once completed, the procedure can be further continued with a retrograde cholecystectomy. Once the cystic duct has been perfectly isolated, clip placement can be combined with a Vicryl loop —which seems to be preferable to the placement of a single clip in this already inflamed context, despite the fact that the intervention took place one or two hours after the perforation. Once the cystic duct has been divided, the cystic artery is clipped and then divided. The gallbladder is then freed from the gallbladder bed using the monopolar electrode of a hook. Once this has been achieved, the gallbladder and the gauze pad that had been placed under the gallbladder are removed.

8. Hemostasis control 05'04''

A last local control of the hemostasis is done using bipolar cautery. This energy device allows for a correct and risk-free hemostasis. A drain will then be placed in the region beneath the liver and just above the duodenal suture in order to direct any potential leakage. The bag will then be exteriorized through the supraumbilical incision.