Laparoscopic cholecystectomy with endoscopic exploration of CBD for suspicion of lithiasis

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Laparoscopic cholecystectomy with endoscopic exploration of CBD for suspicion of lithiasis

Authors

M Simone, J Marescaux

Media type

Surgical video

Duration

07'00''

Publication

2005-02

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E-publication

WeBSurg.com, Feb 2005;5(02).
URL: http://www.websurg.com/doi-vd01en1717.htm

Laparoscopic cholecystectomy with endoscopic exploration of CBD for suspicion of lithiasis

1. Case presentation 00'00''

This is the case of a female patient evaluated for severe abdominal pain toward the right costal margin. Acute cholecystitis is diagnosed. During the evaluation, it is noted that the patient liver chemistries are consistent with a biliary obstruction. After consent from the patient, the patient is anesthetized with a general anesthetic.

2. Patient position and trocar placement 00'27''

Orientation of the patient is a standard supine position, with the legs abducted and the surgeon standing between the legs. The optical trocar is positioned below the umbilicus and four 5mm trocars are placed subcostally. Additionally, ultrasound demonstrates the dilatation of the common bile duct and there is also the suggestion of a stone at the distal portion of the common bile duct approximately 4 to 5mm in size.

3. Exposure 00'55''

Due to the concern for difficult stone retrieval, a laparoscopic cholecystectomy with common duct exploration is advised. To aid with exposure, the round ligament of the liver is suspended using umbilical tape and a Keith needle advanced percutaneously. Adhesiolysis is performed to free the adhesions above the gallbladder. Dissection above Calot’s triangle allows for the exposure of the cystic duct and the cystic artery. This is the initial step in the performance of a cholecystectomy and also our preferred method for preparing for the cholangiogram and duct exploration.

4. Dissection of Calot\'s triangle 01'38''

The 2 objectives of identifying the biliary and vascular anatomy as well as secluding the gallbladder from the stone advancement into the common duct are completed with these initial steps. Once Calot’s triangle has been dissected, the cystic artery is clipped and divided. The cystic duct is then ligated with the use of a 2/0 suture adjacent to Hartmann’s pouch. This completes the seclusion of the gallbladder from the rest of the biliary system. In order to aid in our evaluation of the biliary tract, we cut the cystic duct to allow for the performance of a transcystic cholangiogram. Our suspicion for the presence of a stone is again raised with the cholangiogram. The lack of contrast filling the distal duct as well as the dilated duct warns further investigation. As the cystic duct is fairly short and narrow, we forego an attempt to advance the choledochoscope through the cystic duct as we fear we may cause an injury to the common duct. We therefore prepare to gain entrance via the common duct. The anterior part of the common duct is dissected free with the opening of the peritoneum. Our anatomical structures in this case are now well defined. This image shows the location of the common duct and the hepatic artery.

5. Choledocoscopy 03'12''

The anterior part of the common duct is opened with a scalpel. We then use scissors to enlarge the longitudinal incision. A choledochoscope is inserted in the 5mm port and then advanced through the incision with saline irrigation flowing. Exploration of the common duct and intra-hepatic ducts does not reveal the presence of a stone intraductal tumor for evidence of extrinsic pressure on the duct at the side of the abnormality on the cholangiogram. We explore the anatomy outside the duct with a choledochoscope in place. We find no mass either. We do not have the aid of intraoperative ultrasonography otherwise we would have confirmed with this as well. It is likely that we passed the stone with the pressure of the contrast from the cholangiogram or more likely from the irrigation from the choledochoscope upon its own insertion into the duct.

6. T-tube placement and CBD closure 04'12''

We then place a T-tube drain. One trick we have found to be useful is to tie one limb of the T-tube to the catheter to provide an easier placement of the tube in the duct. Although not always required it can save time with larger ductal incisions where the length of the limbs need to be longer. The incision is approximated with 4/0 absorbable suture. The cystic duct is divided and the gallbladder is then dissected from the liver bed.

7. Cholecystectomy 04'43''

The gallbladder is placed in a retrieval bag and removed. Postoperatively the patient improved with the return of her liver chemistries to normal. A T-tube cholangiogram confirms the lack of an intraductal stone. The T-tube is removed 4 weeks later after another cholangiogram revealed the biliary anatomy to be normal.