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Laparoscopic Management of Biliary Stone Disease
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Laparoscopic Management of Biliary Stone Disease |
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Laparoscopic Common Bile Duct
Exploration: Trans-cystic duct |
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As previously mentioned, the number of laparoscopic
common bile duct explorations performed on our surgical service has
dramatically decreased over the past few years. These explorations are now
rare and usually performed in post-cholecystectomy patients with
Choledocholithiasis who have failed endoscopic retrieval. We strongly
believe Choledocholithiasis is best treated by non-surgical methods such as
an Endoscopic Retrograde Cholangiography and Papillotomy.
Two techniques are used to perform a common bile duct
exploration via laparoscopy. These are 1) the cystic duct dilatation and
retrieval and, 2) the anterior choledochotomy. Nowadays, we almost
exclusively use the laparoscopic anterior choledochotomy.
Pre-exploration
Work-up: A correct diagnosis should be
made prior to the actual initiation of the procedure. An intraoperative
cholangiogram or another imaging study should demonstrate common bile duct
pathology unequivocally.
Operating
Room Set-up:
Additional
Instruments and Hardware:
 | A second
Storz Camera with a
monitor |
| 1 - 5 mm trocar (available) |
| Additional Instruments
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| 1 Storz Ureteroscope- 3.0 mm or
3.5 mm with a 1.5 mm working channel |
| 1 Phantom 5 Plus Balloon Catheter
(Microvasive /75cm, 5 Fr./6 mm, 18 Fr.) with Catheter Introducer
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| 1 LeVeen Inflator 10 cc with
Pressure Gauge |
| 1 Glide Wire 0.35/150 cm with
straight tip |
| 1 Segura Stone Retrieval Stone
Basket 2.4F Mini (120 cm) |
The
Technique
| STEP
1: The
Intra-operative Cholangiogram |
This technique is used at the time of a
laparoscopic cholecystectomy. An operative cholangiogram has confirmed the
presence of a common bile duct stone. At this point, a clip has been placed
at the junction of the gallbladder and the cystic duct. The cholangio-catheter
has been removed. The cystic duct should not be cut. An intact common bile
duct is necessary to maintain sufficient tension for easy access into the
cystic duct and the common bile duct.
| STEP
2: Cannulating the Cystic Duct |
The Phantom 5 Plus Catheter is connected to the LeVeen
Inflator with Pressure Gauge. The catheter is inserted via the lateral 5 mm
trocar into the intraabdominal cavity. A long 4.5 mm sealed, steel shaft is
used to minimize air leaks and to facilitate insertion of the catheter into
the cystic duct.
A glide wire is inserted into the central
channel of the Phantom 5 Plus Catheter. This glide wire is inserted into the
Cystic duct and into the common bile duct using direct vision. The dilating
catheter is then passed over the glide wire into the common bile duct. The
balloon of the catheter entering the cystic duct is positioned at the
entrance of the cystic duct. The balloon is inflated for five minutes at 12
atmospheres of pressure. The entrance of the cystic duct has now been
dilated to accommodate a standard 3.0 mm ureteroscope.
| STEP
3: Inserting the
Choledochoscope |
The Phantom 5 Plus Catheter is then removed and
replaced by the ureteroscope. This scope is either connected to an
additional camera and monitor, or to an additional camera with a image
splitter. The ureteroscope is inserted into the cystic duct with a high
pressure saline flow. It is pushed into the common bile duct which is
visualized and fully explored.
| STEP
4: Retrieving the CBD Stones |
Once a stone is seen, the tip of the
ureteroscope is placed proximal to the stone. A Segura Basket is inserted
into the working channel of the ureteroscope, advanced into the common bile
duct and passed beyond the stone. It is then opened and slowly withdrawn
under direct vision. When the stone is in the basket, the basket is closed
and the stone grasped. The entire apparatus, including the ureteroscope and
the wire basket, is pulled out of the common bile duct and the cystic duct.
The stone is then released into the intraabdominal cavity and retrieved in
the usual manner.
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