Bile duct exploration

• Options
  • Intraoperative procedures – trans-cystic exploration, or choledochotomy and exploration.
  • Postop option – ERCP or PTC.

Flush

• Give glucagon 1mg IV or Buscopan 10-20mg IV.
• For Buscopan – wait until you hear tachycardia.
• Flush duct with 60mls of N saline and then repeat cholangiogram.
• Assess anatomy if not successful – size of stones, where they are, how many stones, how wide is cystic duct and common duct.

Laparoscopic trans-cystic bile duct exploration

• Good for patients with a dilated duct, short and straight cystic duct, small distal stone.
• When not to attempt a trans-cystic exploration
  • Long cystic duct (especially with a low insertion)
  • CHD stones (can’t get around cystic duct, bile duct junction)
  • Stones >10mm. 

Fluoroscopy

https://www.youtube.com/watch?v=6vsh3BHvfHY&ab_channel=SAGES-MinimallyInvasiveSurgeryVideos

What to do

• Dissect cystic duct done as far as safely possible.
• Place port close to cystic duct.
• Options
  • Fogarty balloon 3fr or 5fr
    • Pass down to duodenum under fluroscopy, inflate and withdraw
  • Basket
    • Pass a 5fr (normally use a 3fr for IOC) ureteric catheter in the cystic duct
    • Pass basket (nitinol, Nathansen) though ureteric catheter and close around stone.
• Repeat process until the duct is clear
• Do a completion cholangiogram.

If you are not successful you should try and place Laparoscopic biliary stent placement – this will buy time while you wait for ERCP

• Place a guide wire into the duodenum
• Rail the stent into the duodenum
• All under fluroscopy

Choledochoscope

• Transcystic – limited to stones < 6 mm
  • 5-mm choledochoscope
  • Caught in a basket under direct vision

Open CBD exploration

Need a dilated duct, ideally > 8mm to ensure closure without a stricture.

• Laparoscopic Transductal – larger stones.
  • Divide peritoneum over supraduodenal CBD to expose its anterior surface over 2cm (Minimise mobilisation to avoid damage to blood supply at 3 and 9 o clock)
  • 5mm Longitudinal incision on anterior surface with scissors or diathermy
  • Can manipulate duct
  • Options
    • Fogarty balloon
    • Fluoroscopic guided basket
    • Basket and balloon extraction with 5 mm flexible choledochoscope.
  • Can be closed longitudinally (5/0 PDS)
  • Place drain adjacent
• Open
  • Longitudinal incision mid part of anterior wall
  • The duct can be explored as above with a combination of balloon catheter, basket and choledochoscope or with Desjardin forceps
  • If stones are impacted distally, it may be possible to dislodge them by bimanual manipulation of the intra-pancreatic portion of the duct
  • In cases of difficulty may need to Kocherise the duodenum to better manipulate duct
  • Rarely required transduodenal sphincteroplasty
  • Close choledochotomy with interrupted 5/0 PDS
  • Place drain and close -
  • Flushing and use of flexible choledochoscope