Laparoscopic extraction of a CBD stone after failure of ERCP (duodenal perforation)

Laparoscopic common bile duct (CBD) exploration with stone extraction can be performed with high efficiency, minimal morbidity and without mortality. A trans-cystic approach is feasible in most patients, whereas choledochotomy should be restricted to large bile duct stones that cannot be extracted through the cystic duct. This video shows the laparoscopic treatment of a CBD stone in an 85-year-old female patient in whom two attempts at retrograde cholangiography with stone extraction were unsuccessful.

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Laparoscopic extraction of a CBD stone after failure of ERCP (duodenal perforation)

Authors

B Dallemagne, S Perretta, Gf Donatelli, J Marescaux

Abstract

Laparoscopic common bile duct (CBD) exploration with stone extraction can be performed with high efficiency, minimal morbidity and without mortality. A trans-cystic approach is feasible in most patients, whereas choledochotomy should be restricted to large bile duct stones that cannot be extracted through the cystic duct. This video shows the laparoscopic treatment of a CBD stone in an 85-year-old female patient in whom two attempts at retrograde cholangiography with stone extraction were unsuccessful.

Classification

clinical cases

Keywords

Laparoscopic extraction, CBD stone after failure of ERCP, duodenal perforation

Media type

Surgical video

Duration

10'00''

Publication

2009-09

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E-publication

WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2732.htm

Laparoscopic extraction of a CBD stone after failure of ERCP (duodenal perforation)

1. Clinical case presentation 00'07''

This video shows the laparoscopic treatment of a Common Bile Duct stone in an 85-year-old female patient. Her previous surgical history is notable for a cholecystectomy performed 20 years ago. She presented with acute pain at the level of the right hypochondrium and signs of cholangitis. MRI confirmed the presence of a biliary lithiasis with dilatation of the biliary tract. Two attempts of retrograde cholangiography were unsuccessful and the patient was transferred to our department for another attempt at retrograde cholangiography. Unfortunately, during various cannulation maneuvers of the biliary tract, a perforation, or at least, the extravasation of contrast solution was observed during the endoscopy. The duodenal perforation is confirmed by a CT-scan that demonstrates that there is air retroperitoneally and that the common bile duct stone is still present. In this context, we decided to intervene. A laparoscopy was decided upon with typical trocar placement.

2. Division of the adhesions 01'34''

A few adhesions consecutive to the cholecystectomy are identified and freed. The major worry in this procedure is related to the visceral distension related to the insufflation from the attempted retrograde cholangiography, so that exposure of the hepatic region and retraction of the visceral structures that have been dilated by the air may be difficult. A typical adhesiolysis is performed at the level of the gallbladder bed and the approach to the main biliary tract does not cause any major problems.

3. Identification of the biliary tract 02'42''

The biliary tract is easily identifiable thanks to a clip that had been placed during the first procedure.

4. Duodenal mobilization and exploration of the retroperitoneal region 03'05''

Considering the perforation that occurred during the retrograde cholangiography and the presence of air retroperitoneally, a detachment of the duodenum is performed in order to open the retroperitoneum and identify a perforation. Here we can observe the right colon’s dilatation, impeding the region’s exposure. The duodenum is mobilized and the retroperitoneum will be incised. The early stages of a Kocher’s maneuver will be performed and the duodenum is checked. In this patient, no perforations are identified and therefore no surgical act will be carried out on the duodenum. It is most probably a very small perforation that occurred during the passage of the sphincterotomy guide wire. A simple draining of the retroperitoneum seems to be perfectly adequate. We can observe the presence of air in the retroperitoneal space, but there does not seem to be any suspicious liquids. The papilla’s region is easily checked. The absence of bilious liquid allows to rule out a significant perforation. Once the exploration is finished, we turn our attention to the main biliary tract. The preoperative imaging identified a single stone at the level of the common bile duct.

5. Intraoperative cholangiography 06'31''

An intraoperative cholangiography is performed in order to confirm the presence of the stone before the choledochotomy. The cholangiography is performed by direct puncture of the dilated common bile duct. The imaging at the start of the injection confirms this single stone in the biliary tract.

6. Dormia probe insertion and stone extraction 07'30''

Following this confirmation, a Dormia basket is passed, under fluoroscopic control, through the short choledochotomy that had been performed for the introduction of the cholangiography catheter, and the stone will be extracted. Considering the size of the choledochotomy, it is important to monitor the stone’s extraction in order to avoid tearing the common bile duct as the stone can be quite large. We observe the Dormia basket containing the stone: the choledochotomy is obviously too small to allow the extraction of this stone, so that it will be enlarged for the extraction. The stone will be brought out by one of the trocar incisions.

7. Cholangiographic control 08'45''

After this extraction, another cholangiography is performed: it confirms that the biliary tract is intact and that there are no remaining stones.

8. Kehr drain 08'56''

A Kehr drain will be placed through the choledochotomy with two aims in mind: the cholangiography identified a tight papilla; the risk of postoperative distension is therefore important and an ideal choledochotomy cannot be performed. Secondly, if surgery is required at the level of the papilla, a guide wire can be passed through this Kehr drain and allows a “rendez-vous” with the endoscopist. This will therefore guide an eventual secondary sphincterotomy, if needed. At the end of the procedure, a drain is left in contact to the choledochotomy.