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LAPAROSCOPIC TRANSCYSTIC COMMON BILE DUCT EXPLORATION IN AN INFANT

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.

DOI: http://dx.doi.org/10.17797/wrw1syb8d5

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 Contrast allergy
Tips for set-up: 1. C-arm 2. Fluoroscopy compatible operating room table
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
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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.
Intra-operative: 1. Inability to clear CBD stones (requiring conversion to open CBD exploration or post-operative ERCP) 2. Bleeding 3. CBD injury Early post-operative: 1. Retained stone (requiring conversion to open procedure or post-operative ERCP) 2. Pancreatitis 3. Bile leak (Requiring percutaneous drainage, endoscopic biliary stent, or open operative intervention) 4. Surgical site infection 5. Bleeding Late post-operative: 1. Retained or recurrent CBD stones 2. Trocar site hernia 3. CBD stricture
None
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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.

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