Exploration of the Common Bile Duct:

The Laparoscopic Approach

• Contraindications General• ■ High risk patients (ASA III or IV) for whom an endoscopic approach is preferred• ■ Dense peritoneal adhesions due to previous upper abdominal surgery (a limitation• for the laparoscopic approach)• ■ Liver cirrhosis with portal hypertension/severe coagulation disorders• Transcystic• ■ Presence of obstructive cystic valves (associated with a risk of instrumental CD• or CBD injury)• ■ Stones too large for TC stone extraction• ■ Stones located in the common hepatic duct or in intrahepatic bile ducts• ■ Inadequate biliary anatomy of the CD (tortuous, etc.) and the CD–CBD junction• (parapapillary insertion, acute angle of insertion of CD into CBD, etc.)• Choledochotomy• ■ Thin CBD (risk of stricture after suturing)• ■ The presence of severe inflammation (gangrenous cholecystitis, acute necrotizing• pancreatitis, etc.) at the porta hepatis, precluding a safe identification of CBD

• Preoperative Investigations• History and evaluation: Previous and actual clinical history of biliary symptoms• Pain, jaundice, fever, chills, signs of pancreatitis• Laboratory tests: White blood cell (WBC) count, CRP, bilirubin,ALT,AST, alkaline• phosphatase, amylase, lipase, coagulation parameters• Preoperative radiologic Ultrasound, MR cholangiography, endoscopic ultraassessment:• sonography• Conditions for LCBDE• ■ Adequate experience in open biliary surgery and in laparoscopic advanced procedures,• in suturing techniques and in endoscopic techniques• ■ Routine practice of Intraoperative cholangiography (IOC)• ■ Adequate technical environment (instrumentation, fluoroscopy, flexible scopes, etc.)

• Instrumentation/Material• LCBDE is a technically demanding operation requiring:• ■ High volume insufflator• ■ High energy light source• ■ Fluoroscopic intraoperative cholangiographic equipment• ■ Dormia basket or balloon extraction baskets• ■ Flexible endoscope 3.5mm (fine, fragile and expansive)• ■ Contact or laser lithotripsy device (optional)• ■ Laparoscopic knife• ■ Laparoscopic needle holder• ■ Transcystic drain or T-tube