laparoscopic Cbd Explorataion

7/27/2019 laparoscopic Cbd Explorataion

1/44

Laparoscopic CBD

explorationDR.MATHISEKARAN.T


2/44

INTRODUCTION

Laparoscopic cholecystectomy became the standardapproach for removal of the gallbladder, traditional

common bile duct exploration has become an infrequent

procedure.

Techniques have been shown to be both safe and

effective.

The long-term sequelae of sphincterotomy also can beavoided with laparoscopic bile duct clearance


3/44

The Transcystic Approach to

Choledocholithiasis

Primary aproach via cystic duct avoid incision in CBD.

Current transcystic management of bile duct stones requires

competence in intraoperative cholangiography.

Cholangiogram performed under fluoroscopy adds minimal

time to the procedure-identifies the small percentage of unsuspected bile duct stones

-defines ductal anatomy


4/44

After minimally invasive access to

the abdominal cavity is achieved,

laparoscopic ports are placed in a

standard fashion for laparoscopic

cholecystectomy

A-laparoscope

B and C- gall bladder retraction

D- working port

E- cholangiogram catheter


5/44

Following dissection of thegallbladder neck and

identification of the cystic duct, a

surgical clip is placed on the

cystic duct at the level of the

gallbladder.

A small cystic duct incision

is fashioned just below the clip

and its lumen is

Identified.


6/44

A 5-Fr cholangiogramcatheter is inserted

percutaneously in a location that

will facilitate further access to the

cystic duct and common bile duct

the catheter is flushed with

saline to clear it of air. A dissector

is used to advance the catheter

into the ductotomy and is then

secured with a non-occlusive

surgical clip.


7/44

A Normal cholangiogram

demonstrating all pertinent

anatomy

BAbnormal cholangiogram

CUltrasound demonstrating

common bile duct stones

(arrows).


8/44

A normal cholangiogram will demonstrate the entire bile ductwithout filling defects. Unobstructed flow should be

demonstrated into the duodenum, through the cystic

duct/common bile duct junction and through the bifurcation

of the hepatic duct with filling of the intrahepatic biliary

radicals.

If a normal cholangiogram is observed, the catheter can

be removed, the cystic duct may be ligated,and thegallbladder can be removed in the usual fashion.

Ifstones are found in the common bile duct or hepatic

ducts, a decision can be made then on how to proceed.


9/44

For common bile duct stones

less than 3 to 4 mm indiameter, an

attempt should be made to

mechanically

flush the stones from the

duct.

Intravenous administrationof 1.0mg of glucagon can help

relax the sphincter of Oddi and

facilitate passage of small

stones.

Four minutes following glucagon administration the cystic duct catheter is flushed with several

10-mL syringes of saline


10/44

A repeat cholangiogram

should be performed. If theduct is clear, the

cholecystectomy can

then be completed in the usual

fashion.

If small gallstones (3 mm orless) remain in the duct but

flow is demonstrated into the

duodenum observation

and expectant management.

Clearing of CBD


11/44

For common bile duct stones that are too large to be clearedby simple flushingremove these stones with a Fogarty

balloon catheter.

A 4-Fr Fogarty is inserted with graspers transcystically into

the common bile duct past the stones.The balloon is then inflated, and the catheter is slowly

withdrawn from the cystic duct with the graspers.

the Fogarty will carry the stones out of the cystic duct and

into the abdomen repeat cholangiogram

gallbladder can be removed


12/44


13/44

Fogarty balloon catheter Dormia stone retrieval basket


14/44

Effective for the removal of bile duct stones in the majority of

cases.A laparoscopic choledochoscope or ureteroscope

with a 1.2-mm working channel allows the removal of stones

under direct vision.

Laparoscopic

Transcystic Choledochoscopy


15/44

Flexible choledochoscope or ureteroscope with 1.2-mm

working channel

Laparoscopic padded graspers for manipulation of

choledochoscope

Second camera and light source for choledochoscope or

ureteroscope

Second video monitor or picture within a picture switch

Pressurized saline connection for working port ofcholedochoscope

Additional Laparoscopic Equipment Needed


16/44

5-French cholangiogram or ureteral catheter

0.035-inch flexible-tipped hydrophilic guide wire

5-French angioplasty catheter with 8-mm balloon or

urethral dilators

12-French abdominal wall introducer sheath

Wire retrieval baskets

Additional Laparoscopic Equipment Needed


17/44

Dilation of the cystic

duct with anangioplasty balloon

catheter.


18/44

Dilating the cystic duct with an angioplasty balloon can

facilitate retrieval of stones and passage of the

choledochoscope through the cystic duct.

An 8-mm angioplasty balloon catheter is placed over the

guide wire into the cystic duct.

Inflated to 6 atm of pressure for 5 minutes. The balloon isthen deflated and the catheter is removed.


19/44

The catheter is then

removed, in a Seldingerfashion, leaving the guide

wire in place.

With the guide wire in

place, a plastic sheathapproximately 12 Fr in

diameter is placed over the

wire through the abdominal

wall.

Allows safe passage of

the choledochoscope and

other equipment into the

abdomen without injuring


20/44

a 3-mm inner cannula, of

the type commonly used to

pass an endoscopic ligation

loop, can also be usedthrough a standard

laparoscopic port to pass

the choledochoscope.

cannula will prevent injury

of the scope by the ports

valve and may be less

expensive than other

sheaths.

Seldinger technique


21/44

The Seldinger

technique is used in

combination with a rigid

scope with a working

channel. A soft filiform

wire or a thick suture is

inserted through thechannel. The scope is

withdrawn and a

ventricular catheter is

slid down the wire. The

remainder of the shuntis inserted in the usual

fashion.

Seldinger technique


22/44

Once visualized in the abdomen, the scope can be advanced

into the cystic duct with graspers,which are padded toprotect the flexible scope.

A separate camera, light source, and monitor are then used

to observe the interior of the ducts.

Adequate visualization of the duct interior requires that

pressurized saline is connected to a working side port of

the choledochoscope

A water-tight valve is needed on the end of the working port

to prevent the spray of saline while guide wires and

baskets are used in the scope


23/44

Once a stone is encountered, the guide wire is removed and

a wire retrieval basket is inserted through the workingport.

Underdirect vision, the stone is grasped within the basket

and the stone is pulled back against the end of the scope.

The retrieval basket, scope, and stone are removed from the

common bile duct and then the cystic duct as one unit.

The stone is then released in the abdomen in a convenient

location where it can be found later for removal with the

gallbladder


24/44

Troubleshooting

Inability to advance the scope through the cystic duct tortuous and long,

multiple valves

Solution pass the angioplasty balloon or urethral dilators and dilate the duct

given sufficient time to dilate

Examine the original cholangiogram and dissect the cystic duct toward

the common bile duct junction.

There will typically be a section of cystic duct near the common duct

which is more straight and direct. Second ductotomy can be created in the cystic duct more distally.

leave enough cystic duct to safely ligate the duct at the completion of

the procedure


25/44

Troubleshooting

Stone that is impacted in the ampulla

Solutions stones can frequently be advanced through the ampulla into the

duodenum gentle pressure on the stone with the tip of the scope until the

duodenum is visualized.

CAREFULincrease the risk of postoperative stricture and

pancreatitis


26/44

Troubleshooting

Stones found in the hepatic ductsSolutions dissection of the cystic duct can be performed safely to the

level of the common bile duct, allowing a near 90 angle

between these ducts. The head of the choledochoscope should be angled

proximally once in the common bile duct, and the scope

should be directed toward the hepatic ducts

can enable passage of the choledochoscope into theproximal system and removal of stones

Direct


27/44

very distal insertion of the cystic duct into the common bileduct

very small cystic duct

numerous stones (>5),stones that are too large to be

brought out through the cystic duct stones located in the proximal hepatic ducts

Direct

Laparoscopic Choledochotomy


28/44

Endoscopic stone removal

For ducts less than 8 mm in diameter

significant overlying inflammation.

Laparoscopic choledochotomy

large common bile ducts that are easily visualized.

when endoscopic stone removal is not practical or is

impossible secondary to patient anatomy ( priorantrectomy).

Endoscopic stone removal


29/44

Following

cholangiography, the

anterior common bile

duct is identified near its

junction with the cystic

duct.

The cystic duct is

ligated


30/44

An endoscopic ligating

loop should be used for

large cystic ducts.

The tissue overlying the

common bile duct is

cleared bluntly or with

assistance of ultrasonic

dissection.


31/44

Electrocautery is to beavoided to prevent injury

to the common bile duct.

The initial ductotomy is

made with small, sharp

scissors. The incision

is extended just far

enough

to allow removal of thestones and T-tube

insertion.


32/44

Once the choledochotomy

is created, the stones areremoved with graspers

or a Fogarty balloon


33/44

The choledochoscope can

then be inserted to

inspect the proximal and

distal ducts directly in

order to confirm

clearance of the ductsystem.

Any additional calculi that

are identified can beremoved with retrieval

baskets


34/44

Once the duct is visually

clear, a 10- to 14-Fr T-tubeis cut to shape as in an

open exploration.

The T-tube is insertedinto the ductotomy with

graspers.

The ductotomy is then

closed around the T-tubewith 4-0 absorbable

sutures.


35/44

Intracorporeal suturing and

knot tying will reduce

trauma to the edges of the

choledochotomy.

The end of the T-tube ispulled through a lateral port

site, and a completion

cholangiogram is taken


36/44

Several authors have described improved outcomesfollowing primary closure of the common bile duct

without a T-tube.

Following closure of the common bile duct, the gallbladderis dissected from the hepatic bed.

The gallbladder and all previously extracted gallstones are

placed in a laparoscopic retrieval sac and removed fromthe abdomen.

A closed suction drain is placed in the hepatic bed and the

laparoscopic ports are removed.


37/44

Postoperative Care

If a T-tube was placed, adequate time is allowedfor tract formation to occur about the T-tube.

Generally, 10 to 14 days is sufficient.

A T-tube cholangiogram is taken before removalof the tube. Any retained stones may be

removed via theT-tube sinus tract via the

flexible choledochoscope

(Burhenne technique).


38/44

For transcystic exploration with secure duct ligation and anormal postoperative cholangiogram,no supplementary

care is required.

If the sphincter of Oddi was assessed and transgressed by

the choledochoscope,a postoperative serum amylase isreasonable given the small but definable incidence of

pancreatitis.

Postoperative Care


39/44

A former professor of radiology in San

Francisco .

A native ofHannover, Germany, and a graduate

ofMaximilian Medical School in Munich

Dr. Burhenne escaped from the German army

into Switzerland in the closing days of World

War II.

He came to the United States in 1954 and

moved to San Francisco in 1959.

In 1974, he developed the Burhenne Technique

for removing gallstones through bile ducts.

In 1984, after developing a radiologic prostate

procedure, Dr. Burhenne remained awake and

supervised while a colleague performed the

Dr.H.Joachim Burhenne


40/44

The most common biliary complications include

avulsion or perforation of the cystic duct, which areusually detected intraoperatively with a completion

cholangiogram.

Other complications

persistent cholangitis,

pancreatitis,

retained stonesoften can be avoided with proper patientselection and technique.

Most mortality is secondary to co-morbid cardiac and

pulmonary disease.

Complications


41/44

Results

Laparoscopic choledochotomy is highly effective at stoneclearance.

Most series report greater than a 90% clearance

rate.

The complication rate is higherthan transcystic

exploration.

A morbidity range of 5% to 18% is reported, with asimilar mortality rate to that of transcystic exploration.


42/44

Laparoscopic common bile duct exploration does require additional operating

room time and equipment, but it should be within the grasp

of most laparoscopic surgeons.

Patients benefit include fewer invasive procedures, lower morbidity,

and an intact sphincter of Oddi at the completion of

therapy

Conclusion


43/44

Laparoscopic common bile duct exploration has been demonstrated

to be a safe and effective alternative to endoscopic

therapy.

Surgeons who perform laparoscopic cholecystectomy

perform Transcystic duct exploration as well.


44/44

laparoscopic Cbd Explorataion

Documents

Transcript of laparoscopic Cbd Explorataion