Operative technique of laparoscopic cholecystectomy and choledochoscopic bile duct exploration (CBDE)

Instruments for CBDE used included the Olympus^® 3 mm or 5 mm choledochoscope (Olympus, Tokyo, Japan) and Nitinol^® stone retrieval basket (1.5F, 1.7F, and 1.9F) (Boston Scientific, Boston, USA). All cases of CBDE were performed by consultant surgeons (DB, TM, TY, BL, NH) or by trainees under direct supervision of the operating surgeon.

The operation commenced as per a routine laparoscopic cholecystectomy. The cystic duct and cystic artery are dissected in Calot’s triangle to obtain the critical view of Strasbourg. A cystic duct opening is then made with a laparoscopic scissors for cannulation with a catheter for cholangiography. Once choledocholithiasis is confirmed, the operating room is set up as per (Fig. 1). The diameter of the cystic duct is then assessed at this point and a decision is made if the 3 mm or 5 mm choledochoscope is utilized for cannulation.

Theatre setup.

Cannulation of the cystic duct stump with the choledochoscope is performed through either an extra 5 mm port just under the right subcostal margin or with one of the existing working ports. Once in the common bile duct (CBD), the choledochoscope will be pushed distally towards the ampulla. If this step is difficult, then a Jagwire (Boston Scientific) is passed first through a cholangiogram catheter to facilitate passage of choledochoscope as a (Seldinger) technique. Once the stone(s) identified, it will be captured and removed using a Nitinol 1.5F, 1.7F or 1.9F basket, passed down through the working channel of the choledochoscope.

Check choledochoscopy upstream and downstream from site of cannulation of CBD was performed at the end of the exploration to rule out the presence of retained stones. If check choledochoscopy was not feasible, especially upstream, then an operative cholangiogram was performed to verify duct clearance. The use of internal biliary stent and post-operative drain tube were utilized at the discretion of the surgeon. An example of trans-cystic pre-exploration cholangiogram (Fig. 2) and post exploration cholangiogram (Fig. 3) is shown below. In a minority of cases, Nathanson’s trans-cystic bile duct basket (Cook Medical, Bloomington, Indiana, United States) was employed. These were excluded from the study.

Pre-exploration cholangiogram.

Post-exploration cholangiogram.

There were cases that required a choledochotomy for CBD clearance, mainly due to an inability to cannulate cystic duct, or due to presence of large bile duct stone(s). Ideally, the CBD has to be > 8 mm in diameter to be able to progress to choledochotomy. Port positions were similar as described above. CBD was dissected to expose the supra-duodenal portion for about 2–3 cm. A convenient spot on the anterior surface of the CBD was chosen for a longitudinal choledochotomy made with a pair of laparoscopic scissors. The choledochotomy is usually made to the size of the largest stone. Choledochoscope would be inserted via this choledochotomy. Stones were extracted using similar baskets as mentioned before, passed down the channel of the choledochoscope. Once duct clearance was confirmed with check choledochoscopy, the choledochotomy was closed with interrupted 4/0 monofilament non-absorbable sutures. The use of T-tube, internal biliary stent or peritoneal drain was at the discretion of the operating surgeon.