Laparoscopic Management of Biliary Stone Disease

The common bile duct should be equivocally identified. We rarely proceed with a common bile duct exploration if the duct is 1cm or less in diameter. A confirmation of the diagnosis  is imperative either via an intra-operative cholangiography or with an intra-operative sonographic study. A meticulous dissection of the common bile duct is performed using the ENDO SHEARS* Instrument and a non traumatic grasper from the hepatic bifurcation to the superior aspect of the pancreas. A section of the common bile duct of about 2 cm should be exposed. In some cases, the gallbladder is used to give additional retraction as demonstrated in the following picture. An endoscopic suture can be placed on the lower portion of the gallbladder and the lateral aspect of the common bile duct. In most cases however, we perform a choledochotomy without retraction sutures.

The anterior choledochotomy is performed by inserting the ENDO SHEARS* Instrument via the subxyphoid trocar, grasping the common bile duct with an ENDO DISSECT* Instrument (via the lateral trocar) and incising the CBD (15 to 20mm).

Once the choledochotomy is done,  the common bile duct is flushed using our high pressure irrigation device. A Biliary Fogarty Catheter is then used. It is inserted via the subxyphoid trocar and into the common bile duct, run proximally and distally. This step usually retrieves most of the common bile stones.

 

A Choledochoscopy is  performed. An additional camera and monitor are used to connect the flexible 3 mm choledochoscope or ureteroscope. In this setting, larger ureteroscopes can be utilized as the choledochotomy can accommodate larger sizes. Stones are retrieved using a Secura Basket via the working channel of the telescope.

Once the common bile duct is shown to be free of stones, a T Tube is inserted. The T Tube is usually inserted via the subxyphoid trocar after its limbs have been cut (each should be 1.0 cm in length). It is then inserted entirely into the intra-abdominal cavity. An additional 5 mm trocar is inserted in the RUQ. A grasper is inserted via this new trocar to grasp the long limb of the T Tube. The T Tube is then pulled through the anterior abdominal wall along with the trocar. The T Tube is then inserted into the common bile duct, using two graspers or ENDO DISSECT*. The common bile duct is sutured closed with endoscopic sutures. A completion Cholangiogram is then obtained.