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COMMON BILE DUCT EXPLORATION
Dr. Mark PLEATMAN presents a case of laparoscopic exploration of the common bile duct via the cystic duct. The patient had symptomatic cholelithiasis. Routine cholangiography demonstrated the presence of numerous small stones in the common bile duct.
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This diagram shows possible locations for common duct stones. Trans-cystic duct exploration is most suitable for stones below the junction of the cystic duct and common hepatic duct. It is often difficult to maneuver the flexible scope proximally into the hepatic ducts.
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We use a flexible ureteroscope, which comes in sizes of 7 and 9 French. The biopsy channel of the 'scope is equipped with a 2-way port which allows infusion of saline solution under pressure as well as passage of instruments such as baskets or biopsy forceps.
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Once the decision is made to proceed with choledochoscopy, an additional port is placed for passage of the 'scope. It is frequently unnecessary to dilate the cystic duct for introduction of the 'scope.
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The first two photos demonstrate the ampulla of Vater. The third photo as well as the three below show the cystic duct with its spiral valves, as well as several small stones. It is frequently possible to deliver most or all of the stones into the duodenum simply by "herding" them out with the tip of the 'scope and the aid of the saline flowing out through the tip of the 'scope itself.
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Care should be taken to avoid passing the scope itself through the ampulla itself for fear of traumatizing it and causing spasm. I generally complete the procedure by clipping a ureteral catheter in the cystic duct and performing a final cholangiogram. A drain is left after completion of the cholecystectomy. The ureteral catheter can be attached to a bag for drainage, and then clamped before the patient is discharged. One week later another cholangiogram can be obtained on an out-patient basis, and the catheter can be removed. If residual stones are found, the catheter can be used for introduction of a guidewire to assure successful cannulation of the common bile duct during ERCP. The drain is removed a day or so later.
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