Laparoscopic Management of

CBD Stones
Common Bile Duct
Operative Anatomy
Extra Hepatic Biliary Tree
 Common Bile Duct
• 8 cms Length
• 4 to 9 mm Diameter
• Three parts
– Supra Duodenal
– Retro Duodenal
– Intra Pancreatic
Calot & Hepatocystic Triangle
 Calot’s triangle
• Boundaries
– Right - Cystic Duct
– Left - Common Hepatic Duct
– Superior - Cystic Artery
 Hepatocystic Triangle
• Boundaries
– Right - Cystic Duct
– Left - Common Hepatic Duct
– Superior - Inferior Surface of Liver
 Blood Supply
• From Above
– Right Hepatic
– Cystic

• From below
– Gastroduodenal
– Retroduodenal
– Pancreatoduodenal
Confluence Anomalies
Critical View of Safety
 HISTORY

• Courvoisier described the first conventional common

bile duct exploration in 1889 for ductal stones.
• Hamskehr introduced routine “T” tube drainage after
surgical exploration of the common bile duct.
• Mirizzi, an Argentinean developed the art of Intra
Operative Cholangiography.
• Jacobs et al reported the first Laparoscopic Common
Bile Duct Exploration in 1991
 TREATMENT OPTIONS

• ERC/ sphincterotomy + stone removal ± Stenting

• Cholecystectomy + CBD exploration + T tube
• Cholecystectomy + CBD exploration + Primary closure
• Cholecystectomy + CBD exploration + Bypass
• Cholecystectomy alone
 FACTORS AFFECTING CHOICE OF
TREATMENT OPTION

• Age
• Associated comorbid illness (fitness for GA)
• Stone characters – size, number and location
• Diameter of the common bile duct
• Experience of laparoscopic surgeon and therapeutic
endoscopist
 MANAGEMENT

• Three situations:

- Diagnosed preoperatively
- Diagnosed intraoperatively
- Diagnosed post operatively
STONES DETECTED
PRE-OPERATIVELY
 PRE-OP DIAGNOSIS
• Preliminary Imaging investigations.
• Scoring systems to predict the presence of CBD
stones pre-operatively.
• Cotton PB. Am J Surg 1993
• Onken JE, etal. Am J Gastroenterol 1996
• Rijna H, etal. Dig Surg 2000
PRE-OP DIAGNOSIS

Liu et al, Ann Surg, 2001

 PRE-OP DIAGNOSIS
Probability of CBDS CBDS (%)

HIGH 92.6

MODERATE 32.4

LOW 3.8

VERY LOW 0.9

Liu et al, Ann Surg, 2001

Management

Liu etal, Ann Surg, 2001

CHANGING TRENDS
 Associated CBD stones
• Drawback of LCBDE: Placement of T-tube increasing post-
op stay and care as compared to endoscopic Mx.

• Gersin KS, Fanelli RD, 1998,Surg Endosc.

Laparoscopic Endobiliary Stenting as an adjunct to
common bile duct exploration:
“Laparoscopic endobiliary stenting reduces operative morbidity,
eliminates the complications of T-tubes, and allows patients to
return to unrestricted activity quickly.”
• Retrograde biliary stenting – eliminating the endoscopist
from the peri-operative management of CBD stones.
 Biliary drainage In Preoperatively Diagnosed
CBD Stone

• Patients with large dilated CBD

• Multiple impacted stones
• Non removable impacted CBD stones
• Recurrent stones not amenable to ERCP

Cholangitis
Laparoscopic Management -Approaches
Transcystic Cholangiography
• Transcystic approach to CBD

– small sized stone (<8mm or diameter less than or equal to

diameter of cystic duct),
– limited number of stones,
– stones located below the cystic duct junction
– patent cystic duct

Limiting factors: small size, tortuous duct, obstructive

cystic valve, rupture of cystic duct during
instrumentation and low level of insertion of cystic duct.
Choledochotomy approach
– dilated common bile duct >10mm
– calculi >1cm
– multiple calculi
– Impacted calculi
– failed transcystic exploration
– intrahepatic calculi
• The supposed disadvantage of this approach is the
possible stricture of the common bile duct.
 STONE EXTRACTION

• Suction Extraction
• Two hand manipulation
– “milking the CBD”.
• Irrigation
• Balloon manipulation
• Basket maneuvers
• Choledochoscope
 Special Considerations
1. Hypothermia due to irrigating fluids. Use of warm fluid
for irrigation may avoid it.
2. 6th port for retraction of the hepatoduodenal ligament may
be needed.
3. Difficulty in identification of the CBD can be managed by
• Meticulous dissection of the cystic duct down to CBD.
• Needle aspiration.
• Intraoperative ultrasound.
 Lap CBD Exploration
Advantages Disadvantages
Single hospital admission Technically difficult and
Shorter hospital stay demanding
Quicker recovery Requires experienced laparoscopic
Decreased morbidity and surgeon
mortality Requires advanced laparoscopic
Less costly skills
Longer operating time
Not suitable for poor anaesthetic
risk patients
Requires sophisticated and
expensive laparoscopic,
endoscopic, and radiological
equipment
• Indication for biliary enteric
drainage
– Stricture distal bile duct or sphincter
– Marked dilatation of CBD - More than 2cm.
– Multiple or primary CBD stones
– Inability to remove all stones
– Third operation

• Surgical Options
– Transduodenal sphincteroplasty
– Choledochoduodenostomy
– Choledochojejunostomy
Thank You