Common Bile Duct Exploration

Laparoscopic Common Bile Duct Exploration

• proceed as if lap chole

• perform IOC

• IV glucagon & saline flush

• transcystic exploration

  • guide wire f/b choledochoscope

  • basket retrieval

  • Fogarty catheter

• laparoscopic choledochotomy

• close cystic duct stump

• place T tube

• close choledochotomy

• place closed-suction drains

• complete as if lap chole

• complications

  • transient hyperamylasemia or pancreatitis

  • retained CBD stones

  • bleeding

  • bile leak

  • duodenal injury

Open Common Bile Duct Exploration

• widely Kocherize duo (until you can visualize L renal vein)

• 5-0 Vicryl to 3 & 9 o'clock positions of CBD (avoids blood supply)

  • elevate CBD before choledochotomy (don't backwall!)

• longitudinal choledochotomy at distal CBD (just above pancreatic parenchyma)

  • if difficult to identify duct, use a 27 G needle to visualize bile

  • use a #12 or #15 blade to avoid backwall injury, widen w/Potts-Smith vascular scissors

  • Fogarty 14-18 Fr catheter to flush stones & debris

  • palpable stones: retrieve w/stone grasping forceps

  • insert choledochoscope, confirm ampulla & proximal CBD are patent

  • close over T-tube (pediatric feeding tube)

  • T-tube cholangiogram in 6-8 weeks

• if choledochotomy fails: surgical sphincterotomy

  • longitudinal incision along D2-D3, anterior aspect (palpate ampulla of Vater)

  • sphincterotomy at 10-11 o'clock (avoid injury to pancreatic duct)

  • close duodenum primarily

• widely lay drains 18 Fr Blake drain in Morrison's pouch