1. IN THE NAME OF GOD

2. Laparoscopic Ultrasound of the Biliary Tree
Laparoscopic ultrasound (LUS) is a safe, effective, sensitive, an specific technique for detecting
stones in the common bile duct (CBD) during laparoscopic cholecystectomy.
It is quicker to perform than cholangiography and is a non-invasive method of preventing and
determining CBD injury.
Indications for LUS in Cholecystectomy
1. Detecting choledocholithiasis
2. Detecting bile duct injury
3. Difficult or ambiguous anatomy
4. Unsuspected mass

3. Technique
1. Dissect the cystic duct.
2. Ligate or clip the cystic duct before performing LUS but do not transect until after LUS.
3. Check the probe to determine the orientation of the image on the ultrasound screen.
4. Pass a 5-mm laparoscope through a right upper quadrant port and use it to visualize
placement of the ultrasound probe.
5. Place the probe on segment 4B of the liver .Visualize the gallbladder to look at wall
thickness and for stones or masses.
6. Place the probe on the porta hepatis with the tip in the liver hilum.
7. The head of the pancreas, pancreatic duct, ventral and dorsal pancreas may be
Visualized.
8.The CBD can be followed transversely until it joins the pancreatic duct near or at the ampulla.

4. Benefits
1. LUS has only the one-time cost of the ultrasound machine and probe.
2. There is no radiation.
3. Although user dependent, it may be used on “normal” anatomy to gain
experience and as such allows for the identification of abnormal anatomy.
4. There is virtually no contraindication to ultrasound.
5. There is no risk of cystic duct or common duct injury during LUS.
6. LUS is as reliable as IOC in detecting choledocholithiasis.
7. In experienced hands, minimal intraoperative time is used.
8. LUS can be performed on patients with contrast allergies.
9.in pregnancy is an effective tool

5. Laparoscopic Common Bile Duct Exploration : Transcystic Duct Approach
Indications
The most common indication for LCDE is an abnormal intraoperative cholangiogram .
Preoperative abnormalities that suggest that laparoscopic common bile duct( LCDE) may be
required include the following: history of jaundice or pancreatitis, elevated liver function tests,
sonographic findings of a dilated ductal system, bile duct stones or CBD obstruction,
or endoscopic (ERCP) findings of choledocholithiasis.
Contraindications
The most significant contraindication to LCDE is inability of the surgeon to perform the maneuvers
required for LCDE. Absence of any of the indications listed above , instability of the patient, and local
conditions in the porta hepatis which would make exploration hazardous are other contraindications.
Choice of Approach
There are two possible routes for LCDE. The transcystic duct and laparoscopic choledochotomy.

7. transcystic duct approach
Patient Position
a. Place the patient in the supine position with both upper extremities tucked at the patient’s sides
if possible. In obese patients, one extremity may need to be abducted; in this case, abduct the
right upper extremity, not the left.
b. Reverse Trendelenburg position and rotation to a slight left lateral decubitus position are
often helpful in displaying the porta hepatis.
Trocar Position
a. Place a 10-mm port at the umbilicus.
b. Place 5-mm ports under direct laparoscopic vision in the epigastrium just to right of the midline,
in the right midclavicular line, and in the right anterior axillary line.

8. Techniques transcystic duct approach Irrigation Techniques
When very small stones (<2 mm diameter), sludge, or sphincter spasm is suspected to be
responsible for lack of flow of contrast into the duodenum, transcystic flushing of the duct
with saline or contrast material is occasionally successful in clearing the duct.
a. Intravenous glucagon (1–2 mg) administered by the anesthetist may relax the sphincter
of Oddi and improve the success rate.
b. Monitor the progress, or lack thereof, fluoroscopically.
c. Surgeons should not expect this method to be successful in clearing stones 4 mm
and larger from the duct.

9. Techniques Balloon Techniques
Fogarty TM type, low pressure, balloon-tipped catheters are sometimes useful in clearing
the ductal system of stones or debris.
For Distal Stones:
a. A long 4-Fr sized catheter is inserted into the 14-gauge sleeve used for
percutaneous cholangiography.
b. The insertion site for the sleeve is usually located 3 cm medial to the midclavicular port.
c. Guide the catheter through the cystic duct into the common duct with forceps introduced
through the medial epigastric port.
d. Advance the balloon catheter all the way into the duodenum, at which point the 10 cm
mark on the catheter will have just entered the cystic duct.
e. Inflate the balloon and withdraw the catheter slightly. Confirm the location of the papilla by
observing movement of the duodenum as the catheter is moved.

10. transcystic duct approach
Balloon Techniques
f. Deflate the balloon, withdraw it an additional centimeter, and reinflate.
g. Withdraw the catheter until the balloon exits the cystic duct orifice.
h. Repeat this maneuver until no debris or stones exit from the cystic duct orifice.
For Proximal Stones:
a. Use a 3-Fr Fogarty TM catheter for intrahepatic stones.
b. Insert the catheter through the cystic duct.
c. Advance the catheter past the stone.
d. Inflate the balloon and withdraw the catheter until it exits thcystic duct or the choledochotomy.

11. Techniques transcystic duct approach Basket Techniques
Basket stone retrieval methods may be used in cases where unsuspected stones are
Encountered while the nursing team is preparing the choledochoscope.
They are also useful in somewhat rare cases in which the patient’s CBD is of such small
diameter (<5 mm) that choledochoscope passage would be difficult or hazardous.
There are three primary methods of basket stone retrieval: under fluoroscopic control, under
choledochoscopic control, or freely without either visual monitoring method.

12. transcystic duct approach
Techniques
Basket Techniques
a. In the fluoroscopic method , insert the basket through a 14 gauge sleeve, (an IV sheath),
placed 3 cm medial to the midclavicular port.
Advance the basket through the cystic duct into the CBD with forceps inserted through
the medial epigastric port.
Under fluoroscopic guidance identify and capture the stone in the contrast-filled CBD.
b. When the basket is used in conjunction with the choledochoscope , insert it through the
working channel of the scope.
Capture the stone is under direct vision.

13. transcystic duct approach
Techniques
Choledochoscopic Techniques:
Smaller-diameter (<3 mm) flexible scopes facilitate transcystic choledochoscopy.
even when using such small scopes, the cystic duct may need to be dilated in order
to allow passage of the scope.
Adequate dilatation is usually possible if the initial cystic duct diameter is greater than
2.5 mm, and unlikely if it is not.
In general, if the duct will not initially accept a 9-Fr dilator easily, then adequate
dilatation to the requisite12 Fr is unlikely.
Insert the choledochoscope is through the midclavicular port and guide it into the
cystic duct with atraumatic forceps inserted through the medial epigastric port.
Advance the scope into the common duct and locate the stone(s).
Capture the most proximal stone first to avoid difficulty in removing it from the duct. -

14. transcystic duct approach
Techniques
Choledochoscopic Techniques:
Insert the basket through the working channel of the scope and advance it to the stone
under direct choledochoscopic vision.
Advance the closed basket beyond the stone. Open the basket and pull back, capturing
the stone within the basket.
Close the basket firmly but gently around the stone to secure and not crush the stone.
Remove the entire ensemble through the cystic duct.

15. transcystic duct approach
Techniques
Intraoperative Sphincterotomy:
In this method, a sphincterotome is passed through the working channel of the
choledochoscope and through the sphincter.
Drainage Procedures:
Biliary bypass procedures may be indicated in patients with an impacted distal stone,
a stone or stones located distal to a stricture, or in patients with dramatically dilated ducts
(>2 cm) with multiple stones.
Choledochoenterostomy may be accomplished laparoscopically, but requires significant
advanced laparoscopic suturing skills.

16. Laparoscopic Common Bile Duct Exploration via Choledochotomy
Indications
1. Large single (>6–8 mm) or multiple stones.
2. Stones proximal to the junction of the cystic duct and CBD.
3. Severe inflammation within the triangle of Calot (not including the CBD) may render
cystic duct manipulation difficult.
4. Failure of trans cystic approach, provided that CBD is greater than 8 mm.
5. Failure of endoscopic stone extraction for large or occluding stones.
6. Any or all of the above; if laparoscopic skills sufficient to achieve good operation.

17. and slightly rotated to the left.
Laparoscopic Common Bile Duct Exploration via Choledochotomy
Patient Position:
Position the patient supine as for laparoscopic cholecystectomy, in reverse Trendelenburg,
and slightly rotated to the left.
Performing the Choledochotomy
dissection in the triangle of Calot with visualization of the cystic artery. The cystic duct has
already been partially transected to allow for the IOC.
Identify the supra duodenal CBD as a bluish green tubular structure adjacent to the cystic duct.
Bluntly dissect the peritoneum overlying the CBD with atraumatic graspers. If there is difficulty
clearing the peritoneum, carefully use laparoscopic scissors to help divide the peritoneum.
Clear the anterior surface of the CBD for approximately1–2 cm.
Make a longitudinal incision into the anterior wall of the CBD.

21. Extraction of stones is accomplished with a variety of steps:
Laparoscopic Common Bile Duct Exploration via Choledochotomy
Stone Extraction:
Extraction of stones is accomplished with a variety of steps:
1. Place the suction irrigator into the choledochotomy and irrigate the duct.
2. A Fogarty balloon catheter is inserted through the choledochotomy and guided
distally. Inflate the balloon and gradually withdraw it through the choledochotomy.
3. If the above attempts at clearing the duct are unsuccessful then directly visualizing the duct via choledochoscopy for stone clearance is indicated.
4. Once all stones have been removed, irrigate the CBD again.
5. Perform completion choledochoscopy. We generally guide the scope distally
until the ampulla (or duodenal mucosa) is visualized.

23. Placement of a T-Tube
1. Once the duct has been cleared, prepare an 8 Fr T-tube for placement.
2. Trim the crossbar of the T to approximately twice the size of the choledochotomy (2 cm)
with one side of the crossbar slightly longer than the other and fillet it longitudinally.
3. Grasp the junction of the T with a 2-mm grasper and introduce it through the
epigastric port.
4. Insert the tube into the duct with the long limb in the distal portion of the duct.
5. Use a running suture of 4-0-vicryl to close the choledochotomy.
6. Close the duct from above downward.
7. Exteriorize the T-tube at the end of the surgical procedure through the RUQ
5 mm trocar site.

26. Management of T-tube:
a. Place the drainage bag on the floor for approximately 12 h and check the closed suction drain for any
evidence of a bile leak. If the drainage is not bilious, reposition the bag at the level of the bed for another
12 h. After this time period, place the bag at the head of the bed. If bile is not seen in the closed suction
drain, clamp the T-tube.
b. Remove the closed suction (subhepatic) drain before discharging the patient.
c. Schedule a cholangiogram at approximately 10–15 days after surgery. If there are no retained stones or leak, remove the T-tube.
d. Retained stones can be removed via endoscopy or through the T-tube tract.

28. Cholecysto-choledocholithiasis (CCL)
There are many options to treat CCL, but each one has different advantages and limitations.
Open surgery
A more recent retrospective series reported good results with primary closure of choledochotomy
where endoscopic and minimally invasive facilities are not available.
Currently, open choledochotomy and papillotomy could still play a role in those cases with intraoperative unexpected diagnosis of choledocholithiasis and cholangitis, with bile duct
dilatation or whereall other endoscopic, percutaneous and laparoscopic approaches failed.
Open choledochotomy and papillotomy could also be used in the case of a pre-existing open surgery that
limits the application of endoscopic approaches(i.e., Roux-en-Y intestinal reconstruction after gastrectomy)[

29. Preoperative ERCP (and sub-sequential laparoscopic cholecystectomy)
Cholecysto-choledocholithiasis (CCL)
Preoperative ERCP (and sub-sequential laparoscopic cholecystectomy)
A CBD clearance can be carried out by ERCP with endoscopic sphincterotomy (ES) before LC in many cases,
and it is most likely the most common strategy used in the majority of hospitals worldwide.
this two-stage strategy raises the problem of a close sequence of pre-endoscopic imaging through conventional
US, MRC or EUS and a following LC within a maximum of 72 h that, practically, leads to some organizational
problems in a busy hospital setting.
The other drawback of any two-stage procedure is that the patient undergoes two different uncomfortable
anesthesiologic sessions.

30. Postoperative ERCP (after laparoscopic cholecystectomy)
In those patients with a lower risk of CBDS, a policy of selective IOC and ERCP after LC seems to be rational.
Similar situations are represented by intraoperative diagnosis of CBDS when an endoscopist or a surgeon
trained to perform a laparoscopic bile duct clearance is not available in the operating theatre or in those cases of
misdiagnosed CBDS discovered only after LC.
the main risk of such an approach is to fail a complete bile duct clearance postoperatively and to then have
to conduct further procedures.

31. Intraoperative ERCP (with concomitant laparoscopic cholecystectomy)
The single-stage laparoendoscopic treatment, known as the “Rendez-vous Technique” (RVT), is used to indicat
simultaneous LC and intraoperative ERCP, facilitated by papilla visualization and cannulation through a guide-wire the surgeon inserts into the cystic duct.
A robust review by La Greca , analyzed data from 27 paper which included almost 800 patients and compared the RVT to other approaches.
This research showed an overall bile duct clearance of92.3% and few complications (1.6%-6% bleeding from
the sphincterotomy and 1.7%-7% pancreatitis). These advantages are related to the use of a guide wire that allows a facilitated cannulation of the papilla without the risk of irritating the pancreatic duct.

32. Concomitant laparoscopic cholecystectomy and common bile duct exploration
In this case, the surgeon is able to resolve the patient’s disease completely during the same session,
avoiding the risks of sphincterotomy and without the need to conduct further treatments.
Some surgeons with sufficient expertise in advanced laparoscopy have proposed LCBD as an
excellent option for CCL, but acceptance of such a technique in most hospitals is far off
due to its steep learning curve, especially when a T-tube has to be used.

34. CONCLUSION
Many strategies are available at present, mostly involving LC as a pivotal step in the entire process.
The extremities of the spectrum of treatments are represented by open traditional surgery and
full laparoscopic cholecystectomy with CBD clearance.
However, in the majority of hospitals worldwide, ERCP is the preferred choice used to complete
an LC.
Timing of the ERCP (preoperative, intraoperative or postoperative) is often dictated by the local
presence of professional expertise and resources, rather than by a real superiority of one method
over another.

35. Review Article
Various Techniques for the Surgical Treatment of Common Bile Duct Stones
Abolfazl Shojaiefard,1 Majid Esmaeilzadeh,2 Ali Ghafouri,1 and ArianebMehrabi2
Hindawi Publishing Corporation Gastroenterology Research and Practice Volume 2009

36. LCBDE (trans-cystic or trans-ductal) is a standard method with a high efficacy and low
Morbidity and mortality for the treatment of CBDS in most centers.
Pre- or postoperative ERCP/EST can be use as an alternative method.
We recommend that for patients with CBDS, ERCP should be performed as a first step
and in the event of failure LCBDE can be performed.
It should not be forgot that the open approach always remains as a final option when
others modalities have failed.
Electrohydraulic lithotripsy, extracorporeal shockwave lithotripsy, laser lithotripsy,
And dissolving solutions have especial indications and more clinical trial in this area
must be performed.

37. Management of Common Bile Duct Stones in the Laparoscopic Era
REVIEW ARTICLE
Management of Common Bile Duct Stones in the Laparoscopic Era
A. Sharma & P. Dahiya & R. Khullar & V. Soni & M. Baijal &P. K. Chowbey
Indian J Surg (May–June 2012)

38. CBD stones are usually treated with sequential treatment by EST followed by laparoscopic
cholecystectomy.
However, recent studies indicate that single stage laparoscopic management might be the
preferred option in established centres especially if the patient has multiple stones with
a dilated CBD.
In patients presenting with cholangitis and jaundice, it may be advisable to relieve
the biliary obstruction by EST and then perform laparoscopic cholecystectomy.
If laparoscopic experience is limited, it is advisable that CBD stones should be removed
by either pre or postoperative EST and laparoscopic cholecystectomy.
Finally if laparoscopic exploration fails it is prudent to convert to open exploration of CBD,
remove the ductal stones and perform a biliary drainage procedure if indicated.

39. Schwartz’s Principles of Surgery Tenth Edition(2015)
Choledocholithiasis
Common bile duct stones may be small or large and single or multiple, and are found in 6% to 12%
of patients with stones in the gallbladder. The incidence increases with age.
Commonly, the first test, ultrasonography, is useful for documenting stones in the gallbladder
(if still present), as well as determining the size of the common bile duct.
Magnetic resonance cholangiography (MRC) provides excellent anatomic detail and has a
sensitivity and specificity of 95% and 89%.
Endoscopic cholangiography is the gold standard for diagnosing common bile duct stones.
Endoscopic ultrasound has been demonstrated to be as good as ERCP for detecting common
bile duct stones (sensitivity of 91% and specificity of 100%), but it lacks therapeutic intervention
and requires expertise, making it less available.

40. Schwartz’s Principles of Surgery Tenth Edition(2015)
Treatment
For patients with symptomatic gallstones and suspected common bile duct stones, either
preoperative endoscopic cholangiography or an intraoperative cholangiogram will document
the bile duct stones.
If an endoscopic cholangiogram reveals stones, sphincterotomy and ductal clearance
of thestones is appropriate, followed by a laparoscopic cholecystectomy.
Laparoscopic common bile duct exploration via the cystic duct or with formal choledochotomy
allows the stones to be retrieved in the same setting.
If the expertise and/or the instrumentation for laparoscopic common bile duct exploration
are not available, a drain should be left adjacent to the cystic duct and the patient scheduled
for endoscopic sphincterotomy the following day.
An open common bile duct exploration is an option if the endoscopic method has already
been tried or is, for some reason, not feasible.
Retained or recurrent stones following cholecystectomy are best treated endoscopically.