Bile Duct Exploration : Laparoscopic

Indications
Abnormal IOC
ERCP is successful >70-90% of the time, depending on who's doing it.
- but often pts exposed to ERCP and will have a normal study, and ERCP + S has high morbidity (perhaps 10%) and a definite mortality rate (perhaps 1%)
Choice of approach should be based on local expertise and patient factors
- have to be experienced to get good results and must be able to be versatile with different options to truly succeed.
Contraindicated if instability, hazardous patient or abdominal conditions eg portal hypertension or severe inflammation.
Success rates >90% in experienced hands (80% of transcystic; depends on stone size).
Length of stay
- 1.5d for transcystic, up to a week for trans-CBD.
Should you be able to do it?
Yes if you are a biliary tract surgeon, otherwise probably not unless doing a great volume of gallbladders.
- why better: treat in one procedure, with shorter stay, not exposed to morbidity of ERCP.

Special Preparation
Can approach through cystic duct or by choledochotomy
- transcystic preferred first option; less invasive; less morbid; better outcomes.
image
Choledochotomy must be avoided if duct <6mm, marked inflammation or surgeon inexperienced / poor suturing ability.
Cystic duct route avoided if aberrant cystic duct anatomy / entrance into CBD, small <4mm, stones >6mm.
Warn anaesthetist it will take at least an hour, given setup time, complex patients, additional procedures etc.

Prep
Need for transcystic basket retrieval:
- glucagon 1-2 mg
- Riddick-olsen clamp
- insert large yellow cholangiogram catheter (?4Fr)
- connect to Y-connector, flush.
- zero-tipped ureteric stone extraction basket / catheter
- saline flush
- contrast
Need for choledoscopy
- second camera, stack, scope pressurized water, 4-0 or 5-0 vicryl
- T-tube
- side-viewing scope if going to attempt sphincterotomy.

Procedure

Irrigation Techniques

Glucagon 1-2 mg IV by anaesthetist
- then gently flush after 10-30s with saline and repeat IOC
- good for very small stones <3mm or sludge, otherwise it won't work.

Transcystic retrieval

1. Intubate duct with cholangiogram catheter through riddick olsen clamp
2. Under II guidance feed down correct limb of biliary tree toward duodenum.
3. Identify stone.
4. Pass basket catheter, past stone, pull back, open basket, retrieve stone advancing catheter as closing down on stone.
5. Retrieve via cystic duct.

Balloon Techniques

14 Fr Fogerty used down common duct, inflated and withdrawn
- will "usually" pull stone back into cystic rather than hepatic duct; then use table position to return it to the CBD.

Choledochoscopic

When other methods fail.
Guide scope into duct, saline instillation through working channel for visualization
Need both hands one on controls, one on scope
Watching 2 screens at once, manipulate scope so stone seen and insert basket down working channel to retrieve.

Lap Choledochotomy
1 cm incision down duct, or as big as largest stone.
- use sharp lap scissors
- do not
place stay sutures.

Completion
1. Completion cholangiogram.
2. Close cystic duct with clips +/- endoloops
3. Close choledochotomy, with or without T-tube
- if residual ductal obstruction
- if ductal access required for imaging
- if residual stones.
4. Drain if choledochotomy

T-tube
--> 14Fr T-tube, prepare by removing back wall of T portion.
--> place in abdo via 10mm port, insert top of T into duct, close CBD with 4 or 5-0 vicryl, interrupted sutures.
--> pull tube out of 5mm RUQ port with direct route inject saline, ensure not leaking else resuture.
Remove somewhere between 4 days and 6 weeks - "most appropriate plan lies somewhere between these two extremes".
Disadvantages:
- bacteraemia, dislodgement, obstruction, fracture.
- complications of removal include bile leak, peritonitis, re-operation

Why not primary closure of choledochotomy?
No evidence against it, advantages of shorter time, better patient satisfaction.
No formal evidence either way it seems.
Use t-tubes if concern for retained debris, distal spasm, pancreatitis, general poor tissue quality, severe infection.

Post-Op
LFTs

Complications
Morbidity 8%; usual surgical complications
But very leak rate, low mortality and serious complications in experienced units

Alternatives and Controversies
ERCP