Laparoscopic CBD Exploration

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Essential equipment: 

  • Two 5mm, Two 12mm disposable trocars
  • Two 5mm fenestrated grasping forceps
  • 5mm Maryland forceps
  • Clip applier
  • two 5mm needle holders
  • Suction irrigation
  • 20 Fr drain
  • 3mm Choledochoscope or ureteroscope
  • Espiner knife
  • Stone retrieval non-retracting forceps (Boston Scientific ref., 350-101)
  • Stone retrieval basket (ACMI ref., 7511230) is an alternative

Learn the anatomy & how to carry out a laparoscopic ultrasound.  Scan the CBD every time you undertake a laparoscopic cholecystectomy.
 
Clip the cystic duct just below Hartmann’s pouch leaving the cholecystectomy for the end as this allows better exposure of CBD through lateral traction.
 
Complete dissection of the distal cystic duct makes trans-cystic manoeuvres easier.  Complete anterior dissection of the CBD at site of choledochotomy.  Ensure complete haemostasis of the CBD incision before and after choledochotomy.  The choledochotomy should correspond to the size of the choledochoscope.  Incise the CBD with the Espiner knife.

If you are lucky, gentle external pressure on CBD may allow for easy stone extraction.






Manoeuvre the choledochoscope into the CBD and down towards the ampulla.
 



An easier alternative is to divide the cystic duct as it joins the CBD






Allways handle the choledochoscope through its Teflon canula.  Get your assistant to hold the port that you are using.  Instruments can easily damage the choledochoscope.  Views of the CBD are good.  Use a split screen facility if you have one.

Once a stone is seen, place the tip of the choledochoscope proximal to the stone. Insert a Segura Basket or Stone retrieval forceps into the working channel of the choledochoscope and advance into the CBD beyond the stone.
 




Open and slowly withdrawn under direct vision. When the stone is in the basket, close the basket and grasp the stone. The entire apparatus, including choledochoscope and retrieval basket is then pulled out of the CBD. The stone is then released into the intra-abdominal cavity and retrieved in the usual manner.  Ensure that the CBD has been cleared.

If the stones are small it is frequently possible to deliver most or all of the stones into the duodenum simply by "herding" them out through the ampulla with the tip of the 'scope and the aid of the saline flowing out through the tip of the 'scope itself.  Use IV Buscopam to relax the ampulla. 

Turn off the irrigant if a stone is impacted at the ampulla.  Try to dissimpact with a vascular foggarty catheter.  Irrigate once dissimpacted.
 
Place a retrieval bag in the sub hepatic space if there are lots of stones.
 
Use a continuous suture of 4/0 vicryl to close the choledochotomy (leave a t-tube if there is major inflammation).  Hold the suture with the left hand needle holders and lift up the CBD - makes it easier to suture.  Repeat the ultrasound of the CBD.

Place a sub hepatic 20Fg drain for 24 hrs (introduce using a grabber passed from within through a 5mm port).



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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
claire.TRENBERTH@spirehealthcare.com
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