LAPAROSCOPIC TRANSCYSTIC COMMON BILE DUCT EXPLORATION IN AN INFANT

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

0.038 Glidewire guidewire
4 mm 30 degree laparoscope
5 mm bladeless Step trocar x 3
Balloon retrieval catheter
Endoloop
T-fastener
Taut cholangiogram catheter
Veress Needle

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

N/A

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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