Procedure
- During lap chole
- After adequate dissection and establishment of critical view of safety
- Key steps
o Milk the cystic duct into GB to remove obvious stones
o Place clip at GB/CD junction
o Small incision in CD in anterior border in transverse fashion taking care not to transect it
o Milk any stones back through defect to ensure clear
o Load 3-4Fr ureteric catheter into Riddick-Olsen clamp and I pass this down my medial RUQ 5mm port with 5mm catheter protruding from the end and angles 30 degrees
o Catheter passed into cystic duct and advanced 10-15mm and clamped
o Flow checked with saline flush. There should be free flow with minimal resistance and no leak seen
o Return patient to supine position and remove all equipment in the XR field
o Ensure lead screen positioned if no gown worn
o Check position and orientation. Tip of OR clamp in centre of screen and orientation checked with artery forceps
o Connect diluted contrast and screen XR as inject
o May need positon alteration, more flush, change position to achieve adequate views
o Once happy, catheter and clamp removed, patient positon returned and Lap chole continues
Features
- Five features
- Duodenal flow
- Proximal filling of the common bile duct
- Three proximal hepatic ducts (right anterior, posterior sectoral and left main ducts)
- Absence of filling defects within the common bile duct
- The presence of spiral valves within the cystic duct
- Head down for poor liver filling
- 1 mg glucagon or 10-20mg Buscupan for poor duodenal filling or to help pass a stone
Outline the pros and cons of performing this investigation on a routine basis.
Pros can cons
- Pros
- Detects previously unexpected CBD stones
- Helps identification of abnormal duct anatomy
- Has been shown to reduce CBD injury rate
- Without = 0.4-0.6%
- With = 0.2-0.4%
- Has been shown to improve identification of CBD injuries and picked up early
- Improves operative Skill
- Improves interpretation
- Cons
- Cannot be performed in up to 10%
- Doesn’t eliminate CBD injury
- Just part of process and no replacement for meticulous dissection
- Small unexpected stones are likely clinically insignificant anyway Increased operating time and cost?
- False positives and negatives