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TRANSCYSTIC COMMON BILE DUCT EXPLORATION.
Dr. Juan Pekolj, staff surgeon of the Hepato-biliary-pancreatic service at Hospital Italiano, in Buenos Aires, Argentina is presenting a case of transcystic common bile duct exploration(TCCBDE).
This is a 50 year old male admitted to the Department of General Surgery with the diagnosis of biliary pancreatitis. Following 48 hours of good response to medical treatment, the patient was taken to the operating room where he underwent a laparoscopic cholecystectomy and a common bile duct exploration.
NOTE: Gallstones are formed in the gallbladder and can migrate into the main "bile" pipeline that carries bile from the liver into the gut. Small stones can pass spontaneously to the lumen of the gut, however big size stones can get "stuck" in the conduit (choledocholithiasis) and produce abdominal pain, yellow skin discoloration (jaundice), dark urine, sepsis and sometimes death. The treatment is based in removing the stones from the main biliary conduit (common bile duct) and restore it's patency. This operation is routinely performed with an open technique. Those with advanced laparoscopic skills, as is the case with Dr. Pekolj, are able to employ a laparoscopic approach.
Indications: An abnormal cholangiogram showing or suggesting choledocholithiasis; cystic duct larger than 4 mm merging into the hepatic duct at a straight angle; CBD stones less than 6 mm of diameter; common bile duct less the 6-mm; minimal tissue edema.
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The cystic duct was already dissected and opened to perform a cholangiogram.This study has shown an obstruction in the distal common bile duct (CBD) therefore exploration is warranted.
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Once, the decision to perform a trans cystic approach is made, the dissection of the cystic duct is extended closer to the CBD.
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Next, the cystic duct is divided with scissors.
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The cystic duct has been divided and a cannula is negotiated through it to perform a cholangiogram
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Abnormal cholangiogram showing no passage of the contrast material into the duodenum. This finding is interpreted as CBD obstruction. The incidence of common bile duct stones on routine cholangiograms has been calculated to be approximately 10-20%.
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Dilation of the cystic duct is achieved by inserting balloon catheter into the cystic duct. The device is inflated to dilate the cystic duct no wider than the diameter of the CBD. The balloon is kept inflated for three minutes at 10-12 atmospheres of pressure.
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4F six-wire basket is introduced into the CBD making sure not to severe it during insertion. The catheter should be advanced down to the papilla into the duodenum. It position is confirmed with fluoroscopy showing the catheter marker above the papilla. Catheter entrapment is the cause of bleeding and pancreatitis. The basket is then opened and under fluoroscopic guidance the stone is engaged, applying a rotational movement to the basket while pulling out. If the stone is too big to pass the cystic duct, more pressure should be applied to the basket wires with the goal of fragmenting the stone.
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More contrast material is used to verify the anatomy and the obstruction.
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In this picture the stone has been retrieved and placed into a bag.
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A cholangiogram is performed at termination of the procedure to verify ductal stone clearance and free passage of contrast material to the duodenum. Notice the pancreatic duct joining the CBD into a common duct. An impacted stones in this area will increase the pancreatic duct pressure, mechanism proposed to explain pancreatitis in this particular setting.
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The cystic duct is ligated with an Endoloop to ensure a tight closure.
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Laparoscopy.com would like to thank Dr. Juan Pekolj from the Hospital Italiano, Buenos Aires, Argentina, for his video contribution..
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