surgical exploration of common bile duct

1. SURGICAL
EXPLORATION OF
THE COMMON BILE
DUCT
BY: MOHAMMAD MASOOM PARWEZ, Academic resident
MODERATOR: DR. MAHENDRA PRATAP SINGH

2. Overview
■ Anatomy
■ Indications
■ Pre operative assessment
■ Procedure
■ Post operative care
■ Complications
■ Follow up

3. Anatomy of bile duct
■ Extrahepatic bile ducts consist of:
– Right and Left hepatic ducts
– Common hepatic duct
– Cystic duct
– Common bile duct or choledochus
■ CBD enters the 2nd part of duodenum via
Sphincter of Oddi
■ LHD longer than RHD; join to form CHD
■ CHD: 1-4cm in length; diameter ~4mm;
lies anterior to PV and right of hepatic
artery

4. Anatomical anomalies of cystic duct
■ Variable length and
anatomy
– short and wide or
absent
– Low/high union
with the hepatic
duct
– long and run
parallel, behind,
or spiral to the
main hepatic duct
before joining it
– Joining right
hepatic duct

5. Anatomy of bile duct
■ Spiral valves of Heister: mucosal folds ; no valvular function; makes
cannulation difficult
■ CBD: 7 to 11 cm in length; 5 to 10 mm in diameter
– Supraduodenal portion: upper 1/3rd; lies in free edge of hepatoduodenal
ligament; right of the hepatic artery and anterior to portal vein
– Retroduodenal portion: middle third; curves behind 1st part of duodenum
– Pancreatic portion: curves behind the head of pancreas or traverses
through it to enter into 2nd part of duodenum
■ CBD runs obliquely downward in the duodenal wall for 1-2cm before opening on
a papilla (ampulla of Vater); 10cm from the pylorus
■ It unites with the main pancreatic duct and is guarded at the ampulla by
Sphincter of Oddi

7. Anatomy of bile duct
■ Extrahepatic bile ducts lined by
columnar mucosa with numerous
mucous glands in the CBD
■ A distinct muscle layer is not present
■ Arterial supply: Gastroduodenal and the
Right hepatic arteries
– running along the medial and
lateral walls of the common duct
(3 & 9 o’ clock)

8. Indications of surgical exploration
■ Stones discovered by cholangiography during cholecystectomy
■ Open & Laparoscopic approach
■ Indications of Open Exploration:
– Intraop cholangiogram showing stones during open chole
– Stones discovered during lap chole and surgeon is not familiar with
laparoscopic duct exploration
– Palpable stones in CBD during open chole
– Large and multiple impacted stones
– Previous h/o abdominal surgeries; significant cirrhosis
■ Laparoscopic CBD exploration is indicated when stones are discovered on
cholangiography during lap cholecystectomy

9. Preoperative assessment
■ Difficult to diagnose on the basis of history, physical examination and lab
investigations alone
■ Overlapping symptoms of GB and CBD stones
■ Risk factors: increasing age, h/o fever, cholangitis and pancreatitis
■ Independent positive predictors: raised serum bilirubin, AST, ALP, GGT
■ Transcutaneous USG: highly accurate in identifying acute calculous
cholecystitis
– ability to establish the diagnosis of choledocholithiasis is only about 50%,
varying from 30 to 90%

10. Preoperative assessment
■ In 1968, ERCP was introduced as a
diagnostic tool. 5 years later, with
the development of endoscopic
sphincterotomy - therapeutic
modality
– sensitivity of 90%, specificity
of 98%, and a 96% accuracy
– ERCP stone extraction is
successful 80–90% cases by
sphincterotomy and balloon
catheter or Dormia basket
stone retrieval
■ The mortality rate after diagnostic
ERCP is about 0.2%, and by
therapeutic interventions, to 0.5%
■ M/C/Comp : pancreatitis

11. Preoperative assessment
■ CT Scan: Sensitivities of 76–90%, specificity of 97%, accuracy of 94%
– compared with ERCP; without biliary contrast material (sensitivity 65%
and specificity 84%); with oral contrast (sensitivity and specificity >90%);
I/V biliary contrast (sensitivity of 71–85% and a specificity of 88–95%)
– However, when CT was evaluated for identifying duct stones, it had a
sensitivity of only 22% and a specificity of 83%
■ MRCP: diagnostic alternative to ERCP
– T2-W sequences, biliary tract seen as a bright structure without the use
of contrast material, instrumentation, or ionizing radiation
– Stones seen as low-signal-intensity filling defects surrounded by high-
intensity bile
– MRCP sensitivities ranging from 81 to 92% and specificities from 91 to
100% for choledocholithiasis

12. Preoperative assessment
■ EUS: diagnostic accuracy of 95% for bile duct stones
– high ultrasound frequencies used (7.5 and 12 MHz)
– resolution of less than 1 mm, making it the best imaging technique
available for the extrahepatic biliary tract
– (sensitivity 98%, specificity 99%, PPV 99%, NPV 98%, accuracy 97%)

14. IOC (steps)
■ To prepare for cholangiography, a ligature is placed proximally at the junction
of the cystic duct and gallbladder
■ A small opening is made in the cystic duct and a cholangiocatheter (4-5 F) is
passed into the duct for about 1-2 cm
■ The catheter is secured with a ligature or clip. Two 30 cc syringes are attached
to the catheter with a three-way stopcock and extension tubing
■ One is filled with saline, the other with 50% diluted contrast.
■ Saline is injected to check for any leak. Bile can be aspirated if it is properly
positioned
■ Before injecting dye, air bubbles should be eliminated from the catheter and
tubing
■ The patient is then placed in the Trendelenburg position and tilted to the right
(to bring the common duct “off ” the spinal column)

15. IOC (steps)
■ Contrast is injected under
fluoroscopic guidance
■ Easy flow of contrast
distally into the duodenum
and proximally into the
right and left biliary
radicals along with absence
of filling defects
constitutes a normal exam
■ The catheter is withdrawn
and the cystic duct is
ligated distal to the
catheter entrance site

18. Procedure (open approach)
■ Step 1: Identify the CBD, expose about 2.5-3 cm of its anterior wall
– DO NOT DISSECT ALONG THE LATERAL & MEDIAL WALLS
■ Step 2. A #15 blade to create a small rent in the anterior wall of the duct;
– enlarge the rent in a longitudinal fashion for about 2cm;
– stay sutures are placed on either side (fine 5/0 PDS stay sutures)
■ Step 3: Randall stone forceps are passed distally and then proximally to clear
the duct of stones by directly grasping them
– The duct can be explored as above with a combination of balloon
catheter, basket and choledochoscope
■ Step 4: A choledochoscope is useful to identify residual stones and assist in
their extraction

19. Procedure (open approach)
■ Step 5: An appropriately
sized T-tube is placed into
the common duct, and the
common duct closed over
the tube with a series of
interrupted 4-0 absorbable
sutures
■ Step 6: Cholangiogram is
performed to ascertain that
the duct is clear of stones
■ Step 7: Drain is placed near
the common bile duct
opening and brought out
through a separate stab
incision
■ The remainder of the case
proceeds as for open
cholecystectomy

20. Procedure (Lap)
Laparoscopic Transcystic Duct Exploration of the Common Bile Duct
■ Transcystic duct exploration can be undertaken via the same hole in the cystic
duct created for the cholangiogram
■ Dilation of the cystic duct may be necessary to remove larger stones
■ A balloon catheter setup is utilized to dilate the cystic duct; gradually dilated
over a period of 3-5 minutes.
■ A choledochoscope is used with working channel of at least 1.2 mm. Body-
temperature saline is used to irrigate CBD
■ To remove stones, a straight #4 wire basket (2.4 F) is preferable and should be
threaded through the working channel of the choledochoscope. It is passed
beyond the stone and opened

23. Procedure (Lap)
■ Once entrapped, the stone should be gently
grasped and the basket pulled snugly up
against the end of the choledochoscope
■ Both the basket and choledochoscope are
withdrawn completely as a unit
■ This process is repeated until all stones are
completely removed
■ A completion cholangiogram is performed
■ A T tube for drainage can be inserted if there
is concern for retained stones

25. Procedure (Lap)
Laparoscopic Choledochotomy
■ It requires the surgeon to have the capability to perform intracorporeal
suturing and knot-tying
■ Side-by-side stay sutures of 5-0 monofilament are placed about 2 mm apart in
the wall of the common bile duct, just below the cystic duct-common bile
duct junction
■ A longitudinal choledochotomy approximately 1 cm in length is created using
microdissection laparoscopic shears. Any bile leakage is aspirated
■ Common bile duct is irrigated with body-temperature sterile saline
■ The choledochoscope is placed and similar methods are applied for stone
retrieval/removal

26. Procedure (Lap)
■ Once all stones have been removed, a
T-tube of appropriate size is fashioned
and passed into the abdominal cavity
■ Common duct closed around the tube
with a series of interrupted 4-0
absorbable sutures
■ Suction drain is placed to monitor for
leakage of bile from the cystic duct
closure or the choledochotomy

28. Postop
■ The peritoneal drain can be removed in 24-48 hours if there is no bile leakage.
■ The T-tube is initially placed to gravity drainage. Before discharge, a
cholangiogram through the tube should be performed.
■ If negative, the tube can be capped and the patient discharged
■ For open approach: Diet may usually be instituted within 24 hours. Parenteral
narcotics for pain are switched to oral prior to discharge
■ For Lap approach: Patients are started on clear liquids on the evening of
surgery and discharged after drain is removed

29. Complications
Major complications include:
■ Bleeding
■ Common duct injury
■ Leakage of bile from the cystic duct stump
■ Duodenal injury or other bowel injury
■ Wound infection
■ Complications related to the T-tube are predominantly dislodgement or
kinking
■ Retained stones may be present on follow-up cholangiogram
■ Bile duct stricture can be a long-term complication

30. Follow-up
■ About 2 weeks after surgery, the T-tube may be removed after normal
cholangiography
■ Patients should be followed short-term at intervals until tubes are removed
and liver function tests are normal
■ Most patients experience excellent relief of pain; 5% of patients will continue
to have discomfort as they experienced preoperatively (post-cholecystectomy
syndrome)

32. References
■ Northwestern Handbook of Surgical Procedures
■ Maingot’s Abdominal Operations 12th edition
■ FARQUHARSON’S TEXTBOOK OF OPERATIVE GENERAL SURGERY 10th edition
■ Kirk’s General Surgical Operations 6th edition
■ Schwartz's Principles of Surgery, 10th Edition
■ Makhan Lal Saha Bedside Clinics in Surgery

33. THANK YOU