Contributors: Stephanie Chao, David Worhunsky, James Wall, and Sanjeev Dutta
This video depicts a laparoscopic transcystic common bile duct exploration in a 2 month old infant who was found to have a 1 cm common bile duct stone.
Endoscopic retrograde cholangiography (ERCP) has emerged as part of the standard of care in the management of adult choledocholithiasis. However, pediatric ERCP expertise is limited due to a lack of formal training programs in therapeutic endoscopy for pediatric gastroenterologists and low case volumes, even in pediatric referral centers. ERCP in small infants (weight <8-10kg) is particularly rare and poses additional endoscopic technical challenges, including limited availability of proper instrumentation. In such cases, surgical stone extraction remains a mainstay of therapy. To reduce surgical morbidity, laparoscopic CBD exploration has been attempted in the pediatric population and has demonstrated feasibility (1-4). However, in very small children and infants, the procedure remains technically challenging.
To address the rare infant patient presenting with symptomatic choledocholithiasis, we devised a laparoscopic transcystic common bile duct exploration with stone removal using a balloon retrieval catheter over a guidewire under fluoroscopic guidance. This was performed in a 2 month old (5 kg) infant who presented with a symptomatic 1 cm common bile duct stone.
Jaundice, symptomatic choledocholithiasis, hyperbilirubinemia, common bile duct dilation by ultrasound, choledocholithiasis by MRCP
Intrahepatic bile duct stones
Inability to tolerate pneumoperitoneum
1. Routine laboratory work-up with CBC, serum amylase, lipase, bilirubin, aspartate aminotransferase, and alkaline phosphatase
2. Imaging with ultrasound or MRI/MRCP with signs of CBD stones
Laparoscopic CBD exploration has advantages over both open exploration and ERCP for treatment of choledocholithiasis. The benefits of laparoscopy over traditional open surgery in terms of post-operative pain, length of hospital stay, and return to activity has been well established. A two-stage approach for management of choledocholithiasis with ERCP followed by laparoscopic cholecystectomy has become widely accepted, but is not without disadvantages. The two-stage approach requires that a child undergo anesthesia twice. Pediatric patients who underwent laparoscopic CBD exploration were shown to have a shorter length of stay and decreased hospital costs compared with patients who had ERCP followed by laparoscopic cholecystectomy with similar success and post-operative complication rates (5).
Potential disadvantages of laparoscopic CBD exploration include the need for intra-operative fluoroscopic capabilities and available surgeons who are trained in laparoscopic biliary surgery. In addition, performing a laparoscopic CBD exploration may significantly increase operative time compared with laparoscopic cholecystectomy alone.
1. Inability to clear CBD stones (requiring conversion to open CBD exploration or post-operative ERCP)
3. CBD injury
1. Retained stone (requiring conversion to open procedure or post-operative ERCP)
3. Bile leak (Requiring percutaneous drainage, endoscopic biliary stent, or open operative intervention)
4. Surgical site infection
1. Retained or recurrent CBD stones
2. Trocar site hernia
3. CBD stricture
1. Shah RS, Blakely ML, Lobe TE. The role of laparoscopy in the management of common bile duct obstruction in children. Surg Endosc. 2001;15(11):1353-5.
2. Bonnard A, Seguier-lipszyc E, Liguory C, et al. Laparoscopic approach as primary treatment of common bile duct stones in children. J Pediatr Surg. 2005;40(9):1459-63.
3. Lau BJ, Sydorak RM, Shaul DB. Laparoscopic techniques for safe and successful removal of common bile duct stones in pediatric patients. J Laparoendosc Adv Surg Tech A. 2014;24(5):362-5.
4. Muller CO, Boimond MB, Rega A, Michelet D, El ghoneimi A, Bonnard A. Safety and efficacy of one-stage total laparoscopic treatment of common bile duct stones in children. Surg Endosc. 2015;29(7):1831-6.
5. Short SS, Frykman PK, Nguyen N, Liu Q, Berel D, Wang KS. Laparoscopic common bile duct exploration in children is associated with decreased cost and length of stay: results of a two-center analysis. J Pediatr Surg. 2013;48(1):215-20.