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Laparoscopic Management of Biliary Stone Disease

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Laparoscopic Management of Biliary Stone Disease
Laparoscopic Common Bile Duct Exploration: Trans-cystic duct

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:

bulletA second Storz Camera with a monitor
bullet1 - 5 mm trocar (available)
bulletAdditional Instruments
bullet1 Storz Ureteroscope- 3.0 mm or 3.5 mm with a 1.5 mm working channel
bullet1 Phantom 5 Plus Balloon Catheter (Microvasive /75cm, 5 Fr./6 mm, 18 Fr.) with Catheter Introducer
bullet1 LeVeen Inflator 10 cc with Pressure Gauge
bullet1 Glide Wire 0.35/150 cm with straight tip
bullet1 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.


Procedural Videos
> Standard Lapchole -3267

> Standard Lapchole - Acute-789

> Subtotal Lapchole-7897

> IOC -3892

> LapCBDE TC -3670

> LapCBDE-AC -7982

> Lapchole w CDC -32090

> Lapchole with SURGICON Clip Applier - 38003

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