Exploration of the Common Bile Duct: The Laparoscopic Approach

Exploration of the Common Bile Duct:

The Laparoscopic Approach

Jean-François Gigot

Introduction

Stone migration is a common situation encountered during the management of gallstones. Common bile duct (CBD) exploration (CBDE) thus remains the cornerstone of complete surgical treatment of gallbladder and common bile duct stones (CBDs).

The first laparoscopic choledochotomy was reported in 1991 by Petelin.

Indications and Contraindications Indications

CBD stone disease

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Failed endoscopic removal of stones Choice of Route

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The choice of optimal strategy for laparoscopic CBDE (LCBDE) will be guided by the features of intraoperative cholangiography (IOC), according to the characteristics of the stone and to the biliary anatomy.

The transcystic (TC) route is chosen when there is:

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A patent cystic duct

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A limited number of stones

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Small stone size (stone size £ cystic duct size)

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Stones located below the cystic duct (CD)–CBD junction

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Adequate biliary anatomy of the CD–CBD junction (the ideal case is a perpendicular angle of insertion of CD into the CBD)

Choledochotomy is chosen when there is:

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Dilated CBD ≥7–8mm

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Accessible porta hepatis (no acute inflammation)

Contraindications General

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High risk patients (ASA III or IV) for whom an endoscopic approach is preferred

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Dense peritoneal adhesions due to previous upper abdominal surgery (a limitation for the laparoscopic approach)

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Liver cirrhosis with portal hypertension/severe coagulation disorders Transcystic

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Presence of obstructive cystic valves (associated with a risk of instrumental CD or CBD injury)

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Stones too large for TC stone extraction

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Stones located in the common hepatic duct or in intrahepatic bile ducts

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Inadequate biliary anatomy of the CD (tortuous, etc.) and the CD–CBD junction (parapapillary insertion, acute angle of insertion of CD into CBD, etc.)

Choledochotomy

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Thin CBD (risk of stricture after suturing)

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The presence of severe inflammation (gangrenous cholecystitis, acute necrotizing pancreatitis, etc.) at the porta hepatis, precluding a safe identification of CBD

Preoperative Investigations

History and evaluation: Previous and actual clinical history of biliary symptoms Pain, jaundice, fever, chills, signs of pancreatitis

Laboratory tests: White blood cell (WBC) count, CRP, bilirubin, ALT, AST, alka- line phosphatase, amylase, lipase, coagulation parameters Preoperative radiologic Ultrasound, MR cholangiography, endoscopic ultra-

assessment: sonography

Conditions for LCBDE

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Adequate experience in open biliary surgery and in laparoscopic advanced proce- dures, in suturing techniques and in endoscopic techniques

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Routine practice of Intraoperative cholangiography (IOC)

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Adequate technical environment (instrumentation, fluoroscopy, flexible scopes, etc.)

Instrumentation/Material

LCBDE is a technically demanding operation requiring:

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High volume insufflator

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High energy light source

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Fluoroscopic intraoperative cholangiographic equipment

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Dormia basket or balloon extraction baskets

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Flexible endoscope 3.5mm (fine, fragile and expansive)

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Contact or laser lithotripsy device (optional)

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Laparoscopic knife

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Laparoscopic needle holder

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Transcystic drain or T-tube

Procedure

Incision

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Same four-trocar technique as for laparoscopic cholecystectomy.

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An additional atraumatic soft fifth trocar is placed below the right costal margin, serving as the port for the introduction of the scope.

Exposure

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LCBDE is performed during cholecystectomy after completion of IOC, when the dissection of Calot’s triangle is completed, the gallbladder remaining in place

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The hepatoduodenal ligament is stretched by pulling up on the quadrate lobe.

The patient is placed in an anti-Trendelenburg position to allow gravity to pull

down on the duodenum.

Laparoscopic Transcystic CBDE

STEP 1

Introduction of instruments

The cystic duct incision done for performing IOC is used for transcystic CBDE (TCBDE). Care is taken to avoid a cystic duct incision too close to the CBD, in order to reduce the risk of instrumental CBD injury. The incision must also not be too far from the CBD, because the presence of obstructive cystic valves may preclude instrumental TCBDE. If the caliber of the sufficiently large CD is not dilated enough, it can be care- fully dilated using a soft, flexible dilator, with care taken to avoid instrumental CBD injury.

STEP 2

Instrumental stone extraction

Stone extraction through TCBDE can be performed using a three-wire soft Dormia basket with three different approaches:

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By blunt introduction of the instrument into the CBD through the CD.

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Under fluoroscopic guidance (safer for ensuring stone capture and avoiding instru- mental CBD injury).

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Under visual cholangioscopic guidance (for small stones).

A balloon catheter is not used during TCBDE, in order to avoid stone migration in the

upper part of the CBD. In the case of huge, impacted, obstructive stones not amenable

to extraction by using standard instrumental or endoscopic methods, the stone can be

fragmented by using an endoluminal electrohydraulic or laser lithotripsy probe under

endoscopic visual control.

STEP 3

Stone clearance assessment

The assessment of complete stone clearance is performed in two different ways:

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By control cholangiography.

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By using flexible choledochoscopy (A-1,

scopic or visual guidance into the CBD to assess the presence of residual CBDs. When used through a TC approach, choledochoscopic stone clearance assessment is usually only possible in the lower part of the CBD, except in the case of a wide angle of inser- tion of the CD into the CBD. In this case (15–20% of cases), the scope can be guided into the upper part of the biliary tract.

In case of residual CBDS, an additional endoscopic attempt at stone extraction can be performed by introducing a Dormia basket through the operative channel of the scope, and also by guiding stone capture under visual control. When the number of stones is limited and when stone clearance is complete, the CD can be primarily clipped.

When doubt exists about the completeness of stone clearance, the CBD can be drained by using a transcystic duct drain, carefully secured with an endoloop or an extracorporeal suturing technique.

STEP 4

Routine subhepatic drainage is used.

Laparoscopic Choledochotomy

STEP 1

The anterior wall of the CBD is additionally dissected within the porta hepatis, by using blunt or instrumental dissection (avoiding the use of electrocautery close to the CBD).

STEP 2

A longitudinal incision is made with a laparoscopic knife into the CBD after having

blown up the CBD with saline solution through the transcystic cholangiographic

catheter. The size of the incision is dependent on the size of the largest CBDS to be

extracted from the CBD.

STEP 3

Stone extraction

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By blunt introduction of a Dormia basket or a balloon catheter through the choledo- cholithotomy (A-1,A-2).

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Under endoscopic visual control by introducing a Dormia basket or a balloon catheter through the operative channel of the flexible scope.

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If a large, obstructive stone is encountered, an endoscopic electrohydraulic or laser

lithotripsy technique can also be used.

STEP 4

Stone clearance assessment

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Is performed only by the use of a flexible choledochoscope through the choledo- chotomy. In this setting, a complete assessment of the lower and upper biliary tract is easily possible, up to the intrahepatic bile ducts (A-1,

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In case of residual CBDs, endoscopic stone extraction can be performed under

visual control.

STEP 5

Suture of the choledochotomy

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Closure of the choledochotomy is performed by using interrupted or continuous suture with resorbable 4-0 or 5-0 stitches.

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The use of resorbable or nonresorbable clips to block a continuous suture of the choledochotomy is contraindicated, to avoid further intraductal clip migration.

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At the end of the suturing, a water-tightness test is employed by blowing the CBD through the TC cholangiographic catheter, before clipping the CD or through the T-tube.

STEP 6

CBD drainage

Several options can be used, including primary closure of the CBD (see Step5), external biliary drainage (by a TC drain or a T-tube) or internal drainage (using an endoprosthesis).

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Primary CBD closure: is used when there is no doubt about the complete CBD vacuity, in the absence of severe cholangitis and when papillary obstruction is absent (permeable sphincter of Oddi, absence of edema due to transpapillary instrumental maneuvers, etc.).

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External biliary drainage: by using a transcystic drain (see TCBDE) or a T-tube. In case of T-tube placement, the tube is fenestrated and then inserted into the CBD through the choledochotomy. The CBD suture is started after having pushed the tube at the upper corner of the choledochotomy (A). Then the T-tube is exteriorized through the site of the fifth trocar.

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Internal biliary drainage using an endoprosthesis:

– Indication: When the number of CBDs is limited, the stone clearance is accurate and in the absence of pancreatitis or Oddi dysfunction.

– Technique: The endoprosthesis is pushed under fluoroscopic guidance on a guidewire into the CBD and through the papilla into the duodenum.

Adequate transpapillary positioning is assessed by transcystic cholangiography at the end of the procedure (B).

– The endoprosthesis is removed 3weeks later by a standard duodenoscopy.

STEP 7

Perform control cholangiography at the end of the procedure to detect biliary leak or transcystic drain or T-tube misplacement.

STEP 8

Routine peritoneal drainage is used.

Postoperative Tests

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Clinical assessment

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Check biliary drains

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Laboratory tests: liver function tests, pancreatic enzymes

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Control cholangiography at postoperative days 2–3 (before hospital discharge) if a TC or a T-tube drain is in place, to exclude a residual CBDS or a biliary leak

Postoperative Complications

Local Complications

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Residual CBDS

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Bile leak

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Hemorrhage

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Subhepatic abscess

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Late biliary stricture Due to External Biliary Drain

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Patient discomfort

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Electrolyte abnormalities

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Postradiologic cholangitis

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Tube obstruction

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Accidental tube removal

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Wound infection

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Bile peritonitis at extraction

Tricks of the Senior Surgeon

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Look carefully at pictures of IOC to decide the optimal strategy for CBDE;

this will save operative time and decrease possible instrumental complications.

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Use soft, atraumatic instruments in the CBD and perform instrumental TCBDE under fluoroscopic guidance, to avoid CBD injury.

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When the suture of choledochotomy is completed, use a water-tightness test by blowing up the CBD with saline solution or methylene blue through a transcystic cholangiographic catheter or drain or through the T-tube.

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In case of failure of CBDE, postoperative endoscopic sphincterotomy can be

planned. In these circumstances, placement of a transcystic biliary drain will

optimize the success rate of the further endoscopic procedure.

Exploration of the Common Bile Duct:

The Open Approach

Introduction

The first choledochotomy through laparotomy was reported by Kehr in 1896 and was the surgical treatment of choice for many years. However, since the 1990s, the open approach has been increasingly abandoned in favor of the laparoscopic procedure for CBDE.

Indications and Contraindications Indications

After conversion to open cholecystectomy

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When laparoscopic and endoscopic expertise is not available

Contraindications, Preoperative Investigations, Postoperative Tests and Postoperative Complications These are similar to those for LCBDE.

Procedure

Incision and Exposure

Right subcostal or upper middle-line incision. The hepatoduodenal ligament is more

easily stretched than for LCBDE, by pulling up the quadrate lobe using a retractor

and pulling down the pancreatic head by using the assisting surgeon’s hand.

Choledochotomy

Indications and techniques, including methods of stone extraction and stone clearance assessment, are similar to those for laparoscopic CBDE. However, external biliary drainage is classically used during open CBDE (OCBDE), by using either a TC drain or more often a T-tube. However, primary closure of the CBD might be indicated under the same conditions as for LCBDE. Internal biliary drainage is usually not reported during OCBDE.

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Stay sutures are placed on the CBD on either side of the planned choledochotomy, and the CBD is openedless (A).

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The common duct stone is then extracted either by choledochoscopy (B-1) or by use of stone forceps (B-2).

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The CBD is then closed over a T-tube (C).

A

B-1

B-2

C