Laparoscopic management of CBD stones in acute cholecystitis

This video demonstrates a complex case of a patient with obstructive jaundice and acute cholecystitis. The surgeon performs a transcystic cholangiogram, which demonstrates three large stones in the CBD. The choledochotomy is then made and a choledochoscope is used to visualize the stones. Under direct vision a Dormia basket is used to retrieve the three stones. After the choledochoscopy confirms the absence of any further stones in proximal and distal biliary tree, the choledochotomy is closed with interrupted absorbable sutures over a T-tube. A completion cholangiogram is performed. A Penrose drain is left in place after the cholecystectomy is completed.

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Laparoscopic management of CBD stones in acute cholecystitis

Authors

M Simone, J Marescaux

Abstract

This video demonstrates a complex case of a patient with obstructive jaundice and acute cholecystitis. The surgeon performs a transcystic cholangiogram, which demonstrates three large stones in the CBD. The choledochotomy is then made and a choledochoscope is used to visualize the stones. Under direct vision a Dormia basket is used to retrieve the three stones. After the choledochoscopy confirms the absence of any further stones in proximal and distal biliary tree, the choledochotomy is closed with interrupted absorbable sutures over a T-tube. A completion cholangiogram is performed. A Penrose drain is left in place after the cholecystectomy is completed.

Classification

complex cases

Keywords

CBD stone, jaundice, acute cholecystitis, CBD exploration, choledochoscopy, cholecystectomy, laparoscopy

Media type

Surgical video

Duration

04'00''

Publication

2005-08

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E-publication

WeBSurg.com, Aug 2005;5(08).
URL: http://www.websurg.com/doi-vd01en1737.htm

Laparoscopic management of CBD stones in acute cholecystitis

1. Dissection of Calot\'s triangle 00'10''

We present the case of a 28-year-old woman with acute cholecystitis and jaundice. We begin the procedure with inspection and dissection of Calot’s triangle. There is edema of the gallbladder in the common bile duct area. This situation often makes the procedure more complicated and more hemorrhage is to be expected than usual due to the inflammatory response. As you can see here, it appears that we have found the cystic duct and Calot’s triangle. We clip the cystic artery.

2. Transcystic cholangiography 00'58''

The cystic duct is ligated near the gallbladder preparing to perform a transcystic cholangiogram. We prefer the laparoscopic choledochotomy approach rather than transcystic. An incision is made over the cystic duct and a catheter is introduced to perform a cholangiogram. The catheter is then sutured in place and a cholangiogram is seen. When these stones are seen noting to be a total of 3 in their size, we will now prefer a choledochotomy approach rather than transcystic since we find it easier to perform as we would do in open surgery.

3. Choledochotomy 01'52''

Additionally, with inflammatory response we find less damage that occurred to the patient’s biliary tree utilizing this technique. A knife puncture is made over the common bile duct to initiate the choledochotomy and then completed by scissors.

4. Choledochoscopy and stone extraction 02'19''

A flexible choledochoscope is introduced for a first glance of the common bile duct lumen. The stones are visualized. Dormia basket extraction is then done under visual control through the operatory channel of the choledochoscope. As can be confirmed by the size of the stones we feel it was good judgement to perform the choledochotomy. The stones are gathered in a bag for extraction. At this time, 3 stones were retrieved. A Fogarty catheter can be used as well in this situation however the Dormia basket that did its function. The control choledochoscopy is then done to make sure that no stones are left.

5. T-tube drainage 03'30''

A T-tube is inserted. This does demand some dexterity but usually can be accomplished without too much trouble. The choledochotomy is closed by several stitch sutures with absorbable suture. We utilize 2 sutures with this patient. If endoscopy with papillotomy would have been made in this patient, the size of the stones could have been a problem and a mechanical lithotripter would have been required. In this case, the entire procedure was done laparoscopically even though it was an emergency case. We must express caution while handling the common bile duct in the presence of edema as injury can occur. We feel the laparoscopic common bile duct exploration is safe and feasible even in an emergency basis.

6. Cholecystectomy 04'50''

We will now perform the completion cholecystectomy by our standard laparoscopic technique. After the cystic duct was ligated and sectioned, the gallbladder was dissected freely away from the liver bed avoiding hemorrhage. The gallbladder will then be placed in the retrieval bag along with the stones and removed from the patient. We chose to place a Penrose drain with the patient’s significant edema. Postoperatively the patient will have the Penrose drain in place as well as the T-tube. Finally, prior to completion of the procedure, a completion cholangiography confirms the lack of remaining stones in the biliary tree. After confirmation of this, the procedure is complete.