Contributor: Manish Parikh
The patient is a 50 year-old man with a history of gallstone pancreatitis treated with endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct stent at an outside hospital. The patient subsequently had migration of the stent into the stomach and recurrent choledocholithiasis. This is a video demonstrating techniques used for laparoscopic common bile duct (CBD) exploration via choledochotomy with primary closure of the duct. The intraoperative cholangiogram revealed the “meniscus sign” consistent with a large stone at the ampulla.
Attempts at transcystic CBD exploration failed due to a tortuous duct and inability to pass the fogarty balloon. A laparoscopic choledochotomy was then made for stone extraction. A longitudinal choledochotomy was performed sharply after exposing the anterior aspect of the common bile duct. Intraoperative choledochoscopy confirmed the stone at the ampulla. A 4Fr fogarty catheter was used to extract the stone. Repeat choledochoscopy confirmed clearance of the duct. The choledochotomy was closed with 4-0 PDS sutures in interrupted fashion. The patient’s stent was removed from the stomach via intra-operative Esophagogastroduodenoscopy (EGD) at the conclusion of the procedure.
If the surgeon confirms that the common duct is cleared, the evidence supports primary closure of the duct. In scenarios where the duct is not completely cleared of stones or if there is doubt, closure over a 14-16Fr t-tube is performed.
A 10 Fr. JP is routinely left in the right upper quadrant when a choledochotomy is performed.
Editor Recruited By: H. Leon Pachter, MD