Common Bile Duct

Exploration

LaproscopicBiliary

Drainage procedures

TRANS CYSTIC APPROACH

CHOLEDOCHOTOMY APPROACH

Insertion of suction tube in to choledochotomy with tip pointing towards ampulla

Low suction is applied and stone adheres to suction tip

Stone is delivered, transfered to spoon forceps & removed

An iv injection of glucagon relaxes ampulla which facilitate down flushing of stone in to duodenum

Deflated baloon cathter is guided in to CBD to pass across the ampulla & in duodenum

Inflated & withdrawn until resistanse is felt

Deflated & withdrawn for 1cm

Now ballon is distal CBD

Reinflated

Slowly withdrawn maintaining the inflated position to extract stone

Repeated 2 to 3 times to ensure complete clearence

Dormia basket is introduced through cystic duct or Choledocotomy

Basket guided to distal end of CBD

Slowly withdrawn while wires of basket are opened and closed to catch any stone fragments

Inability to completely close the basket –presence of stones

Basket along with stones are removed in sweeping motion

Repeated till entire CBD is free of stones

This procedure can be

performed under guidence of

ULTRASOUND

CHOLEDOCOSCOPE

This is done with a T-tube closure

Horizontal limb of T-tube is trimmed to a length of 1.5cms & filleted

T-tube is placed In to CBD through Choledocotomy

wound

Incision is then closed by two

or three interrupted

sutures

Other end of T-tube is brought

out through separate stab incision & sub

hepatic drain is placed

Left undisturbed for 2-3 weeks and then removed

Grossly dilated

common duct

Short distal stricture

with proximal dilatation

CBD incised longitudinally for 2.5cms from point at which it traverses duodenum extending proximaly

CBD thoroughly rinsed with warm normal saline

Duodenum incised longitudinally for 1.5cms along superior border

Single layered anastomosis is performed with knots on inner side

No need for T-tube drainage

If duct <2cm, distal

bile duct injury,

malignant obstruction, duodenum not suitable for choledochoduodenostomy

Duct is transected & end to side anastomosisis performed