Common Bile Duct Exploration

Bile duct exploration
Lap trans-cystic exploration
Note there is available evidence suggesting that a watch and wait policy is appropriate when stones found on cholangiogram, other options including pre-op ERCP for clinical or imaging suspicion pre-operatively, lap exploration via cystic duct, open exploration via choledochotomy, post-op ERCP.
Available in Ballarat include Segura hemisphere stone retrieval basket (2.4F) that can be passed down the cholangiocatheter (4 or 5F). Once stone retrieved place a laparoscopic CBD stent (Cook, 7F, 4cm stent with below components included) loading barbed end of stent first onto included guide wire (0.89mm, 145cm). Use positioner (50cm) to place stent in appropriate position.

1.Prior to starting, attempt to flush the stones by administering buscopan 20mg IV, Glucagon 1mg IV, nitrolingual spray and flush the CBD with 200ml of saline.
2.Insert a slippery guidewire into D2 via the cystic duct stump through the cholangiogram catheter.
3.Remove the cholangiogram catheter, replace with Cook extraction kit components and then remove the guidewire.
4.Insert the wire basket into the cystic duct stump, pass it into the duodenum and then withdraw the wire with the basket open. Alternatively, pass the balloon catheter into D2 having blown up the balloon proximally in an attempt to push the stone into D2.
5.Examine the CBD and the IHD with the choledochoscope passed via a RUQ port with sleeve/constant lubrication and distention of CBD with saline to enable easy passage and viewing. This may require balloon dilatation of the cystic duct stump.
6.Alternatively, if a formal choledochotomy is required because of a narrow cystic duct convert to open. Place stay sutures on each side of the planned vertical incision of the CBD. Examine the duct with the scope as above after crossing the stay sutures to provide an adequate seal for distention of the CBD with saline.
7.If there is a suspicion of further stones needing ERCP or perhaps even routinely, re-insert slippery guidewire into D2 and push a Sherman stent (leading barb and trailing pigtail) Be sure of where the radio-opaque markers are as this can be misleading and can cause you to push the stent all the way into the duodenum) down into the ampulla.
8.Close the CBD incision using an interrupted 4/0 PDS. This can be tested by passing the cholangiogram catheter into the cystic duct stump and flushing with saline. You can also leave a biliary drain via the cystic duct stump (size 8 infant feeding tube) or a T-tube brought out through a separate incision which remains in situ for cholangiogram in 6/52.
9.Drain the GB fossa (14F) with a suction drain.

Salient facts about open exploration of CBD
•You will need to Kocherize the duodenum.
•Retrieve stone fragments following choledochotomy using Randall stone removing forceps or Pituitary scoop or Fogarty balloon catheter (4F).
•Options for draining the CBD include a Trans-cystic biliary drain as above, T-tube brought out through a separate incision in the bile duct.