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LAP CBD ppt
1. LAP CBD EXPLORATION
DR SREEJOY PATNAIK
E.C MEMBER EAST ZONE , IAGES
FIAGES FAMS FAIS
G.C MEMBER , ASI, ODISHA
2. POPULARITY OF LAP.CBDE
Is preferred more frequently.
Increasing surgeon’s expertise in Laparoscopy.
Increasing demand of a single procedure .
One time hospitalisation and anaesthesia.
Reduction of costs.
Success rate is 80-90%.
4. INDICATIONS OF TRANS CYSTIC
APPROACH
CBD diameter < 6 mm
Stone location distal to the cystic duct / CBDjunction
Cystic duct diameter > 4 mm
Fewer than 3 to 6 stones within the CBD
Stones smaller than 10 mm
Cystic duct entrance into CBD is straight and lateral
Laparoscopic suturing ability poor
5. Laparoscopic Trans Cystic Duct Approach to CBD stones
Contra-indications
1. Stone diameter > 6mm
2. Cystic duct diameter < 4mm
3. Intra hepatic stones
4. Cystic duct entrance - posterior or distal to CBD stones
Advantages
1. T-tube is eliminated
2. Risk of CBD stricture post. choledochotomy is eliminated
6. INDICATIONS FOR CHOLEDOCHOTOMY
• Failed laparoscopic trans cystic exploration or preoperative ERCP stone
extraction
• Narrow entrance & course of cystic duct ( spiral,very low, post.)
• Valves in the cystic duct.
• Dilated CBD > 1 cm
• Large stones > 10 mm or impacted, requiring lithotripsy.
• Multiple stones
• Intra-hepatic stones.
• Suturing ability -good
7. Laparoscopic choledochotomy for CBD stones
Contra-indications
1. CBD diameter less than 6mm
2. Poor laparoscopic suturing ability
8. FACTORS FOR LAP CBDE
• STONE FACTORS:
• Single stone
• Muliple stones
• Stones< 6 mm
• Stones > 6 mm
• Intra- hepatic stones
DUCT FACTORS:
Diameter of CD < 4 mm
Diameter of CD > 4mm
Diameter of CBD < 6mm
Diameter of CBD >6mm
CD entrance- lateral
CD entrance- posterior
CD entrance- distal
INFLAMMATORY FACTORS:
Inflammation – mild
Inflammation - marked
SURGEON FACTORS :
Suturing ability- Poor
Suturing ability - Good
10. TRANS CYSTIC EXPLORATION
The Steps
Cystic duct preparation .
IOC + confirm stones/location.
Extraction of stone- flushing, wire
basket, balloon.
Fibreoptic Choledocoscopy +
extraction
Completion IOC (Fluroscopy)
Stent CBD(Antegrade) +/-
Close Cystic duct- Endoloop / LT-
400 Clip
11. LAP CHOLEDOCHOTOMY
Important steps
Exposure of CBD
Choledochotomy- 1cm
Rigid / Flex. choledochoscopy
Stone Extraction- saline flush,
endo-basket, endo-balloon.
Stone clearance- mech.lithotrpsy /
Holmium laser, graspers.
Check for residual stones - IOC
Antegrade stent, T-tube, CDD
Primary closure of CBD
12. TRANS-CYSTIC VS CHOLEDOCHOTOMY
Trans-cystic Choledochotomy
No. of CBD stones < 3 Any number
Size of stone Smaller than cystic duct
< 6mm
Any size
Location of stone Below the insertion of
cystic duct
Any location
Anatomy of cystic duct
(long, valve, medial
insertion, low insertion)
Important Not so
Diameter of CBD Any > 7mm
Operating time Less More
Hospital stay Less More
Surgical technique Easy Difficult
Stone clearance 60 – 65% 95 – 100%