LAP CBD EXPLORATION

DR SREEJOY PATNAIK

E.C MEMBER EAST ZONE , IAGES

FIAGES FAMS FAIS

G.C MEMBER , ASI, ODISHA

POPULARITY OF LAP.CBDE

Is preferred more frequently.

Increasing surgeon’s expertise in Laparoscopy.

Increasing demand of a single procedure .

One time hospitalisation and anaesthesia.

Reduction of costs.

Success rate is 80-90%.

LAPAROSCOPIC APPROACHES TO CBD STONES

1. TRANS- CYSTIC DUCT APPROACH

2. LAP. CHOLEDOCHOTOMY APPROACH

INDICATIONS OF TRANS CYSTIC APPROACH

CBD diameter < 6 mm

Stone location distal to the cystic duct / CBDjunction

Cystic duct diameter > 4 mm

Fewer than 3 to 6 stones within the CBD

Stones smaller than 10 mm

Cystic duct entrance into CBD is straight and lateral

Laparoscopic suturing ability poor

Laparoscopic Trans Cystic Duct Approach to CBD stones

Contra-indications

1. Stone diameter > 6mm2. Cystic duct diameter < 4mm3. Intra hepatic stones4. Cystic duct entrance - posterior or distal to CBD stones

Advantages

1. T-tube is eliminated2. Risk of CBD stricture post. choledochotomy is eliminated

INDICATIONS FOR CHOLEDOCHOTOMY

• Failed laparoscopic trans cystic exploration or preoperative ERCP stone extraction

• Narrow entrance & course of cystic duct ( spiral,very low, post.)

• Valves in the cystic duct.

• Dilated CBD > 1 cm

• Large stones > 10 mm or impacted, requiring lithotripsy.

• Multiple stones

• Intra-hepatic stones.

• Suturing ability -good

Laparoscopic choledochotomy for CBD stones

Contra-indications

1. CBD diameter less than 6mm

2. Poor laparoscopic suturing ability

FACTORS FOR LAP CBDE

• STONE FACTORS:• Single stone

• Muliple stones

• Stones< 6 mm

• Stones > 6 mm

• Intra- hepatic stones

DUCT FACTORS:Diameter of CD < 4 mmDiameter of CD > 4mmDiameter of CBD < 6mmDiameter of CBD >6mmCD entrance- lateralCD entrance- posteriorCD entrance- distal

INFLAMMATORY FACTORS:

Inflammation – mildInflammation - marked

SURGEON FACTORS :

Suturing ability- PoorSuturing ability - Good

STANDARD LAP PORT PLACEMENTS

TRANS CYSTIC EXPLORATIONThe Steps

Cystic duct preparation .

IOC + confirm stones/location.

Extraction of stone- flushing, wire basket, balloon.

Fibreoptic Choledocoscopy + extraction

Completion IOC (Fluroscopy)

Stent CBD(Antegrade) +/-

Close Cystic duct- Endoloop / LT-400 Clip

LAP CHOLEDOCHOTOMY Important steps

Exposure of CBD

Choledochotomy- 1cm

Rigid / Flex. choledochoscopy

Stone Extraction- saline flush, endo-basket, endo-balloon.

Stone clearance- mech.lithotrpsy / Holmium laser, graspers.

Check for residual stones - IOC

Antegrade stent, T-tube, CDD

Primary closure of CBD

TRANS-CYSTIC VS CHOLEDOCHOTOMY

Trans-cystic Choledochotomy

No. of CBD stones < 3 Any number

Size of stone Smaller than cystic duct

< 6mm

Any size

Location of stone Below the insertion of cystic duct

Any location

Anatomy of cystic duct (long, valve, medial insertion, low insertion)

Important Not so

Diameter of CBD Any > 7mm

Operating time Less More

Hospital stay Less More

Surgical technique Easy Difficult

Stone clearance 60 – 65% 95 – 100%

VIDEO PROCEDURE

Complications

• Biliary leak (2 to 3%)

• Haemoperitoneum

• Sub-diaphragmatic collection (1-1.4%)

• Bilioma (2.1 – 3.6%)

• Stone over Stent

• Left over stone (2 – 8%)

• Conversion (1 - 4.5%)

BILIO-ENTERIC BYPASS

WHY, WHEN & HOW.

Indications:

Multiple CBD stones

Recurrent choledocholithiasis

Unsuccessful sphincterotomy

Impacted large CBD stones

Markedly dilated CBD

Choices:

Choledochoduodenostomy

Transduodenal

sphincteroplasty/ERCP + ST

Choledochojejunostomy