Ch. 54 – Biliary System

Box 54-4 Indications for Intraoperative
Cholangiogram
Elevated preoperative liver enzymes (AST, ALT, ALP, bilirubin)
Unclear anatomy during laparoscopic dissection
Suspicion of intraoperative injury to biliary tract
Dilated common bile duct on preoperative imaging
Gallstone pancreatitis without endoscopic clearance of common
bile duct
Jaundice
Large common bile duct and small stones
Unsuccessful preoperative endoscopic retrograde
cholangiopancreatography for choledocholithiasis
gallbladder is dissected from the liver bed, starting with
the fundus. Alternatively, the retrograde technique can
be used where the dissection is initiated with the fundus
and the artery and duct identifi ed, ligated, and divided
as a fi nal step. It is important to keep the dissection as
close to the gallbladder as possible, to avoid dissection
into the liver and subsequent bleeding. The dissection is
carried proximally toward the cystic artery and the cystic
duct, which are then ligated and divided.
Common Bile Duct Exploration
In patients with large and multiple stones or dilated
ducts, and when endoscopic therapy fails, laparoscopic
common bile duct exploration is indicated. If unsuccessful,
conversion to open surgery is necessary, whereas
postoperative ERCP should be used as the last resource.
After intraoperative cholangiogram indicates the presence
of choledocholithiasis, the surgeon is faced with many
options. A wide array of techniques and tools are at a
surgeon’s disposal. The initial step is to determine the
important factors regarding which modality of treatment
will best serve the patient. Factors such as diameter and
anatomy of the cystic and common bile ducts, number
and size of CBD stones, clinical status of the patient, and
most importantly, technical skill of the surgeon should
all be considered.
Laparoscopic Approach
If the stones are small, use of saline irrigation through
the cholangiogram catheter to fl ush the stones into the
duodenum is all that is necessary. Relaxation of the
sphincter of Oddi with glucagon may be helpful. If irrigation
is unsuccessful, a balloon catheter may be passed
through the cystic duct and down the common bile duct,
where it is infl ated and withdrawn to retrieve the stones.
The next attempt should be made with a wire basket
passed under fl uoroscopic guidance to catch the stones.
If needed, a fl exible choledochoscope is inserted directly
into the cystic duct (Fig. 54-17). The cystic duct may have
to be dilated to allow its passage. Although most authors
advocate fi rst attempting a transcystic access, there are
clear indications for a direct common bile duct exploration
fi rst. The most common scenarios are the presence
of more than fi ve common bile duct stones, stones larger
than 9 mm, and common hepatic duct stones. Once in
the common bile duct, the stones may be caught into
Chapter 54 Biliary System 1565
Box 54-5 Indications for Open Cholecystectomy
Poor pulmonary or cardiac reserve
Suspected or known gallbladder cancer
Cirrhosis and portal hypertension
Third-trimester pregnancy
Combined procedure
a wire basket under direct vision or pushed into the
duodenum.
When the duct has been cleared, the cystic duct is
ligated and cut and the cholecystectomy is completed. If
the cystic duct cannot be dilated, a longitudinal choledochotomy
should be made on the anterior wall. After
adequate dissection, anterior choledochotomy can be
used. A longitudinal incision is favored because of the
pattern of terminal arterioles supplying the common bile
duct. Postoperative biliary drainage with a T tube may
then be necessary. Clearance of all common bile duct
stones is achieved in 75% to 95% of cases with laparoscopic
common bile duct exploration. 19 Many studies
have shown similar effi cacy of laparoscopic common bile
duct exploration as endoscopic sphincterotomy and laparoscopic
cholecystectomy, while demonstrating signifi -
cant cost analysis in favor of common bile duct exploration
at one setting.
Open Approach
With the increased use of endoscopic, percutaneous, and
laparoscopic techniques to treat common bile duct stones,
the open common bile duct exploration is rarely performed
today. It is now commonly used as a last resort
if the above therapies fail. The techniques and operative
manipulations are similar to the laparoscopic approach.
In patients with a nondilated bile duct (>4 mm), a transduodenal
sphincterotomy should be performed and the
duct explored through the sphincteroplasty. This avoids
the need for a postoperative T tube and the potential for
a late bile duct stricture. With the use of intraoperative
choledochoscopy, the rate of retained common bile
stones is less than 5%.
Drainage Procedures
If the stones cannot be cleared or when the duct is very
dilated (>1.5 cm in diameter), a choledochal drainage
procedure should be performed. Options for biliary
drainage include a side-to-side choledochoduodenostomy
or a choledochojejunostomy with a Roux-en-Y limb
of jejunum. Surgeon preference dictates which approach
is used. Use of the duodenum is preferred if the duodenum
can be fully mobilized (Kocher maneuver) and there
is minimal scarring. Any concerns about tension should
prompt use of the jejunum either as an end-to-side or
side-to-side confi guration.
Transduodenal Sphincterotomy
In the current era, endoscopic sphincterotomy has
replaced open transduodenal sphincterotomy. If an open
procedure for common bile duct stones is being done in
which the stones are impacted, recurrent, or multiple, the