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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: Choledochotomy
 

 Additional Instruments and Hardware:

bulletA second Storz Camera with a monitor
bullet1 - 5 mm trocar (available)
bulletBiliary Fogarty Catheters (5, 6 F)
bulletZsabo-Berci Needle Driver or EndoStitch Instrument
bulletLaparoscopic Sutures
bulletT Tube ( Sizes 12 - 18 should be available)

 The Technique

This can be performed at the time of a laparoscopic cholecystectomy or in the post-cholecystectomy patient. In the latter group, the trocars used are the same as for a standard laparoscopic cholecystectomy.

 

 STEP 1: Exposing the CBD

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.

 STEP 2: The Anterior Choledochotomy

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).

 STEP 3: Clearing the CBD

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.

 

 STEP 4: The Choledochoscopy

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.

 STEP 5: inserting the T Tube

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.


 

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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