Laparoscopic transcystic approach for a complex case of common bile duct stones

Laparoscopic approach for common bile duct stones is effective and safe in single-stage management of gallstones and common bile duct stones. We present the case of a 54-year-old male patient with symptomatic gallstone disease we electively presented for cholecystectomy. The patient was without any clinical or laboratory evidence of common bile duct disease. As well ultrasonography revealed only cholelithiasis. Intraoperatively cystic and common bile duct stones are discovered; a transcystic stones extraction is demonstrated.

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Laparoscopic transcystic approach for a complex case of common bile duct stones

Authors

M Vix, J Marescaux

Abstract

Laparoscopic approach for common bile duct stones is effective and safe in single-stage management of gallstones and common bile duct stones. We present the case of a 54-year-old male patient with symptomatic gallstone disease we electively presented for cholecystectomy. The patient was without any clinical or laboratory evidence of common bile duct disease. As well ultrasonography revealed only cholelithiasis. Intraoperatively cystic and common bile duct stones are discovered; a transcystic stones extraction is demonstrated.

Keywords

Laparoscopic transcystic approach, complex case, common bile duct stones

Media type

Surgical video

Duration

05'00''

Publication

2005-06

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E-publication

WeBSurg.com, Jun 2005;5(06).
URL: http://www.websurg.com/doi-vd01en1738.htm

Laparoscopic transcystic approach for a complex case of common bile duct stones

1. Case presentation 00'09''

We present the case of a 54-year-old male patient with symptomatic gallstone disease we electively presented for cholecystectomy. The patient was without clinical or laboratory evidence of common duct disease. As well ultrasonography revealed only cholelithiasis.

2. Dissection of Calot\'s triangle 00'28''

Upon initial evaluation of the anatomy, we note the appearance of what we believed was a right hepatic artery in our anticipated area of dissection. We noted a chronic inflammatory response at the triangle of Calot which rendered dissection difficult. Initial dissection of the gallbladder from the liver bed was not difficult.

3. Dissection of right hepatic artery 01'00''

However, we take care to note the right hepatic artery crossing anterior to the cystic duct. The right hepatic artery was then dissected free of the inflammatory tissue and retracted out of the way. The artery is very obvious here. We continue dissection with the hook cautery to aid in the visualization of the cystic artery. The cystic artery is identified here. With further dissection of the cystic artery away from the right hepatic artery and common bile duct, we feel safe in knowing that it is supplying the gallbladder directly. Here we show the cystic artery once again. The cystic artery is then clipped and sectioned.

4. Extraction of cystic duct stones 02'32''

With instrument palpation, we can detect the presence of stones in the dilated and elongated cystic duct. Therefore, we open the cystic duct and several stones are identified immediately and extracted. With a gentle milking action, we advance the stones out of the duct and into a bag as is evident here. The stones were impacted and obstructed the cystic duct lumen. The incision on the cystic duct will now need to be enlarged to allow another stone to pass. We feel the stone is right at the confluence of the common duct. After opening the cystic duct further, the nature of the impaction only allowed us to remove the stone and piecemeal as we do not want to cause injury to the common duct. Reflecting on the difficulty of the stone extraction, we believe it would have been quite difficult to remove the stone with conventional endoscopic retrograde techniques. Here we are utilizing a fenestrated grasper as well as a right angle instrument to perpetuate the process. Note that the fenestrated grasper is currently on the cystic duct just above the common bile duct confluence so as to avoid direct injury and possible stricture to the common bile duct.

5. Transcystic cholangiography 04'17''

After saline irrigation in the evidence of free flowing bile, we perform the transcystic cholangiography to investigate further the possibility of choledocholithiasis. The cholangiography was then performed and a single 1cm stone was shown impacted in the common bile duct.

6. Choledochoscopy and stone removal 04'37''

We also note some segmental dilatation. A laparoscopic transcystic cholangioscopy of the common bile duct was then performed. The use of a Dormia basket along with manual manipulation of the duct allowed for its removal. The basket itself was not sufficient in this very stubborn case of cholelithiasis. Reveal of the ductal system of the cholangioscope as well as the completion cholangiogram confirmed the patency of the common bile duct.

7. Cystic duct ligation and cholecystectomy 05'11''

We complete our procedure with the closure of the cystic duct with the use of an Endoloop. Alternatively, needle suturing or GIA stapling could be used to complete this task. Finally, we complete the cholecystectomy with hook cautery. Inflammatory response and edema allow for the dissection to proceed rapidly. We believe the laparoscopic treatment of common bile duct stones is feasible in complicated and difficult cases such as this one, even through a transcystic approach.