Biliary Tract: Surgical Management of the Bile Duct

Intraoperative Cholangiogram (IOC)

Basics

  • Intraoperative X-Ray Imaging with Contrast Through Bile Ducts to Evaluate Anatomy & Stones
  • Routine Use:
    • Unnecessary, Although Practice May Improve Outcomes in More Challenging Cases
    • Likelihood of Finding Unsuspected Stone: 10-15%

Indications

  • Presumed Choledocholithiasis that Passed (Marginal Improvement in Labs)
    • Preoperative ERCP Becoming More Common
  • Concern for Ductal Injury Intraoperatively
    • Allows Earlier Recognition of Injury
    • Prevent Complete CBD Transection (Does Not Prevent Injury)
  • Need to Delineate Ductal Anatomy Intraoperatively

Procedure

  • Obtain the Critical View of Safety as Normal
  • Place Clip Proximally Across Junction of Infundibulum & Cystic Duct (Prevent Reflux)
  • Transverse Incision Through Cystic Duct
  • Milk Duct Contents Back Through the Ductotomy
  • Introduce Cholangiocatheter Through Ductotomy
  • Inject Contrast Under Continuous Fluoroscopic Visualization
    • Evaluate: Ductal Anatomy, Free Flow into Duodenum & Filling Defects
  • Intervention as Indicated
  • Close Stump with Endoloop (Not Clips)
    • Minimize Chance of Leak

If CBD Stone Identified

  • Initial: Give Glucagon (1.0 mg) & Flush with Saline to Release
  • If Fails: CBD Exploration

If No Filling of the Common Hepatic Duct is Seen

  • Concern for Hepatic Duct Injury
  • Initial Steps: Position in Trendelenburg & Partially Retract Catheter to Reimage
  • If Still Fails to See CHD – Convert to Open Procedure to Better Visualize & Evaluate Injury

Laparoscopic Common Bile Duct Exploration (LCBDE)

Laparoscopic Common Bile Duct Exploration (LCBDE)

  • Laparoscopic Exploration of CBD to Remove Stones
  • Comparison to ERCP:
    • Similar Morbidity & Mortality
    • Lower Hospital Length of Stay with Single-Stage Cholecystectomy/CBD Exploration

Transcystic Approach

  • Preferred Approach
  • Contraindications:
    • Friable Cystic Duct
    • Large Stones (> 1 cm)
    • Multiple Stones (> 8)
    • Common Hepatic Duct Stones
    • Narrow or Tortuous Cystic Duct
  • Procedure:
    • Dilate Cystic Duct to 4-6 mm for Instrumentation
    • Retrieve Stones
      • Choledochoscope-Guided Wire Basket – Preferred Method
      • Fluoroscopic-Guided Wire Basket
      • Fogarty/Balloon Catheter
    • Confirm Clearance with Completion Cholangiography
    • Close Duct

Choledochotomy Approach

  • Indications:
    • Failed Transcystic Approach
    • Transcystic Approach Contraindicated
  • Contraindication:
    • CBD Diameter < 7 mm
  • Procedure:
    • Choledochotomy Incision
      • 1.0-1.5 cm Longitudinal Incision Below Cystic Duct Insertion
      • Slightly Medial to Anterior Midline (Avoid Septum of Fused Cystic/CHD)
    • Retrieve Stones – Same Methods as Transcystic
      • Consider T-Tube if Suspect Residual Stones
    • Close with Absorbable Monofilament Suture

Options If Stone Impacted & Unable to Remove

  • Leave T-Tube
    • Not Routine – Increased Risk of Complications/Leaks, Longer Operating Time & Longer Hospital Length of Stay
    • If T-Tube Left – Confirm Clearance with Completion Cholangiography
  • Postoperative ERCP
  • If Preoperative ERCP Failed:
    • Transduodenal Sphincteroplasty
    • Biliary-Enteric Drainage (Side-to-Side Choledochoduodenostomy)
      • Generally Preferred if Multiple Impacted Stones with Dilated CBD

Open Common Bile Duct Exploration

Open Common Bile Duct Exploration

  • Open Exploration of CBD to Remove Stones

Indications

  • CBD Stone During Open Cholecystectomy
  • LCBDE Failure
  • If Endoscopy & Laparoscopy Unavailable

Procedure

  • Ligate Proximal Cystic Duct
  • Choledochotomy Incision
    • 1.5 cm Longitudinal Incision Just Above Duodenum
  • Use Stay-Sutures on Either Side to Keep the Choledochotomy Open
  • Retrieve Stones
    • Manual Expression – Initial Method
    • Fogarty/Balloon Catheter
    • Choledochoscope-Guided Wire Basket – If Balloon Fails
  • Consider T-Tube if Suspect Residual Stones or Concern for Stricture
  • Close with Absorbable Monofilament Suture

T-Tube Postoperative Management

Repeat Cholangiogram at 24-48 Hours

  • If Normal: Keep Clamped & Flush with Saline Once-Twice Per Day
  • If Obstructed/Retained Stone: Leave Open to Drain

Repeat Cholangiogram at 10-14 Days

  • If Normal: Remove
  • If Obstructed/Retained Stone: ERCP or IR Intervention per T-Tube

Transduodenal Sphincteroplasty

Transduodenal Sphincteroplasty

  • Fallen into Disuse with Endoscopic Interventions
  • Now Used Primarily if Endoscopic Sphincterotomy Contraindicated:
    • Recurrent Stricture After Endoscopic Sphincterotomy
    • Ampulla Endoscopically Inaccessible
    • Pancreatic Divisum

Indications (If Endoscopy Contraindicated)

  • Impacted Stone on CBD Exploration
    • If Multiple Impacted Stones May Consider Biliary-Enteric Drainage with Choledochoduodenostomy
  • Very Dilated CBD with Distal Stricture

Procedure

  • Kocher Maneuver
  • Longitudinal Duodenotomy On Lateral Side
  • Cut Papilla at 11 O’clock Through Entire Common Tract
  • Suture CBD Wall to Duodenal Mucosa