Choledocholithiasis: transcystic route

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Choledocholithiasis: transcystic route

Authors

J Leroy, J Marescaux

Keywords

biliary tract,operation,Calot's triangle,cystic artery,cystic duct,gallbladder,lithiasis

Media type

Surgical video

Duration

09'00''

Publication

2003-01

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E-publication

WeBSurg.com, Jan 2003;3(01).
URL: http://www.websurg.com/doi-vd01en1386e.htm

Choledocholithiasis: transcystic route

1. Trocar placement 00'13''

Our patient today has a suspicion for choledocholithiasis. We position the operating room as shown, the surgeon between the patient’s legs. Trocars are as positioned thus. You can see the camera is placed at the umbilicus. Trocars B and C accommodate the operating trocars, and the trocar at the left subcostal margin provides retraction.

2. Freeing of gallbladder 00'41''

First, we have to free the gallbladder and to do so, we need exposure. The duodenum needs to be placed on traction and away from Calot’s triangle. You can see here omental adhesions and with a combination of traction and counter-traction, with exposure on the fundus of the gallbladder, we take down these adhesions. This will open up the space between the gallbladder and the duodenum. You can see below here is the duodenum and we’re trying to separate the plane between the infundibulum of the gallbladder and the duodenum. This can be particularly dangerous and it is important to make sure you are in the right plane as you continue dissection. With continued traction and counter-traction, the space begins to eventually open up. Above the scissors is the gallbladder’s infundibulum and below is the duodenum.

3. Dissection of Calot\'s triangle 02'02''

Calot’s triangle must be meticulously dissected to isolate the cystic duct and cystic artery shown here. This needs to be clipped and ligated. We have the infundibulum on tension now and Calot’s triangle has been opened up and exposed. This manoeuvre shows the terminus of the gallbladder as it comes into the cystic duct and lateral tension at this point is essential to expose Calot’s triangle. We can see now the isolation of the cystic artery just above the scissors. You can see here the cystic duct. We will first ligate the cystic artery, which we believe will be the structure here. This will also help to open up Calot’s triangle, and then we can complete our dissection of the cystic duct. Part of performing the cholangiography is to place a compress below the cystic duct in order to catch any stones that may fall out and any bile leakage from seeping down into the lesser sack to the foramen of Winslow.

4. Cholangiography 03'22''

The first step of the cholangiography is to get proximal control, that is we block off the gallbladder by placing a distal clip on the cystic duct. Then we place a percutaneous angiocatheter, which accommodates our cholangiography catheter. A small incision needs to be made in the cystic duct far from the common duct to avoid injury. We open our cystic duct as shown here and then coagulate the small vessels supplying the cystic duct. You see the bile coming from the distal cystic duct and we will milk the distal end of the cystic duct to make sure that there are no stones in the distal portion of the cystic duct and it looks like we do in fact have a small stone right here. Next we need to introduce the catheter into the distal cystic duct. As you can see, we have a catheter system here that allows blockage of reversal flow from the catheter. Once this is introduced into the cystic duct, it’s opened and this bocks the retrograde flow. We will reinforce this maneuver by clamping on the catheter and you can see the injection of dye here shows evidence of at least one stone in the distal common duct, which appears to be a bit generous in size. There is little flow onto the duodenum as you can start to see now and you can see a non-opaque region consistent with the stone in the common bile duct. Proximal flow seems to be unobstructed; there is no evidence of other stones. You can see in this image clear opacification of the duodenum.

5. Stone extraction 05'21''

Next, we have to extract the stone. A trocar is placed at the site where we had placed our angiocatheter. The 1st maneuver is to dilate the cystic duct to accommodate our choledochoscope. You can see here dilation of the cystic duct. This can be a potentially dangerous maneuver and care must be taken not to tear the cystic duct or injure the common bile duct. Next, we introduce our choledochoscope, which is flexible, through our trocar. As the scope is threaded into the cystic duct, it is advanced distally to the common bile duct and we have an internal view here and you can see our stone that showed up on the cholangiography is clearly visible. Our task at this point is to get the Dormia basket around the stone and extract it. We’ve now deployed the basket and we’ll try to close it around the stone itself, and again this can be a tricky maneuver. Now we’ve a grip on the stone and we can withdraw both the basket and the camera at the same time to ensure that we keep control of the stone. You see us coming around the angulation there. We are now coming out of the cystic duct and we can show you an intra-abdominal view. Here’s the stone trapped in the basket at the distal portion of the scope. And now we can take our camera and stone and basket out and this is an external view. Now we need to take a final look in the common bile duct and make sure that we didn’t leave any stones behind. We are back inside the common bile duct now and this is an internal view of the common bile duct through the choledochoscope. As you can see, it appears that we have no evidence of any further stones. Our intraoperative cholangiography did not indicate any proximal stone so I think since our distal common bile duct is clear, that is probably sufficient. You see us now entering the scope from the cystic duct.

6. Cholecystectomy 07'36''

The next step is the cholecystectomy itself. This is accomplished by dissecting the gallbladder free from the gallbladder fossa. We have a small bleeding vessel, which was feeding the cystic duct. We’ll address that with cautery. Now we’re using an Endoloop device to go around the cystic duct remnant and also address the small bleeding vessel on the side of the cystic duct. The Endoloop is cinched and cut and now we have control on the cystic duct stump. At this point, we need to use electrocautery dissection to remove the gallbladder free from the gallbladder fossa. As you can see, we have a nice dry field; the retraction is atraumatic by opening the grasper. We place the gallbladder into an extraction bag, re-examine our Calot’s triangle. We have hemostasis; there is no evidence of bile leak and the liver bed is dry. We remove the bag and the gallbladder through the umbilicus and the procedure is complete.