CBD exploration
Conditions favouring CBDE:
[edit | edit source]- CBD diameter <7mm
- Stone location distal to cystic duct/CBD confluence
- Cystic duct diameter >4mm
- Fewer than 6-8 CBD stones
- Stones smaller than 10mm
- Lateral entrance of cystic duct to CBD
Technique for trans-cystic
[edit | edit source]- Consider cystic duct dilation with a balloon
- Insert raytec to help catch stones once removed
- Duct access and clearance
- Choledochoscopy
- Dissect down to bottom of cystic duct and make a decent ductotomy, leaving enough room to clip or Hem-O-Lok below
- Second stack, with choledochoscope connected
- Surgeon on patient's right operating the choledochoscope, while assistant holds the port at the ductotomy, and with their other hand holds the GB up
- Either directly access the cystic duct, or place a 0.035-inch guidewire into the duct using the cholangiogram catheter, then thread the choledochoscope over the wire
- Continuous pressurised saline irrigation as the CBD is accessed
- Use through-the-scope Nathanson basket to remove distal CBD stones
- If the stone is large, a larger cystoscope with the Segura basket may be helpful
- Stent
- Additionally, a 7Fr endobiliary stent can be placed across the ampulla if desired
- Wire basket
- Basket types
- Nathanson basket is best for trans-cystic
- Segura - 3Fr, 20mm basket when fully opened, stiffer
- Cook fusion extraction basket - minimum channel 4.2mm, can be done over a 0.035 guidewire, basket diameter 2cm
- Cook Ncompass nitinol stone extractor basket - specifically for surgical stone extraction - 2.4Fr, 115cm, 1.3cm diameter when deployed
- Boston Scientific Trapezoid RX - minimum channel 3.2mm, can be done over a 0.035 guidewire, sizes 1.5, 2, 2.5, 3cm
- Wire through cholangiogram catheter, then withdraw catheter?
- Basket placed over wire and guided to distal CBD
- Open basket and withdraw
- Basket types
- Balloon method
- Advance a 3-5Fr biliary Fogarty balloon into distal CBD. To get the best position, put it in the duodenum just distal to ampulla, then deflate the balloon and withdraw slightly until it can come back nicely.
- Inflate balloon and withdraw carefully until debris/balloon are seen exiting cystic duct
- If the biliary Fogarty catheter isn't long enough, try a vascular Fogarty
- Choledochoscopy
- Closure
- EndoLoop
- Leave a drain
Technique for choledochotomy
[edit | edit source]- Check CBD >1cm diameter
- Can be laparoscopic or open
- Exposure
- Fixed retractor
- Expose supra-duodenal CBD by dividing pars flaccida
- Stay on top of the CBD - blood supply at 3 and 9 o'clock
- 2x 5/0 PDS stay sutures
- Longitudinal incision 1cm with 11 blade, just below confluence with cystic duct
- Remove stones
- Basket
- Fogarty
- Desjardin forceps
- Confirm clearance with choledochoscope
- Close with interrupted 5/0 PDS
- Can also close over a biliary stent or T-tube
- Drain
Technique for duodenotomy
[edit | edit source]- Stay sutures in duodenum
- 3cm longitudinal duodenotomy opposite ampulla
- Insert catheter from distal end of duct to dislodge stone
- If that fails, sphincterotomy at 10-12 o'clock
- Close duodenotomy transversely