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22 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Once the cystic artery has been divided, the gall bladder
is mobilized out of the liver bed (6). I prefer to mobilize it
from above downward. The serosa is opened three or four
millimeters from the liver, and then elevated with a fine clamp.
Using the electrocautery, the serosa is divided from above
downward circumferentially around the entire gall bladder.
The gall bladder is then dissected out of the liver bed utilizing
the electrocautery, sharp dissection using scissors (7), or by
blunt dissection. One needs to be aware that small anomalous
ducts may enter the gall bladder directly from the liver, and
these should be clamped and ligated, or suture ligated. If the
cystic artery has been divided prior to mobilization of the
gall bladder, very little bleeding occurs. Any bleeding
that is present is easily controlled with the electro-
6
Serosal
reflection
cautery or an argon beam coagulator.
Gall bladder
fossa
Mobilized
gall bladder
7
Once the gall bladder has been completely mobilized out of the
liver bed, the anatomy is generally clear, and if the cystic
Open Cholecystectomy 23
Cholangiocatheter
artery has not been previously identified, control of that
vessel can now be accomplished. If one has decided to
perform operative cholangiography, once the gall bladder mobilization has been completed, it is time to
perform the procedure (8).
In most patients with normal liver function, and
no other clear indications for cholangiography, it
will not be necessary. However, in some patients
operative cholangiography will be required. In
patients who have a history of cholangitis or pancreatitis and with multiple small stones in the gall
bladder, many feel cholangiography is indicated. If
the common duct is dilated, and if there has been a
clear history of common duct stones, cholangiography
8
Cystic duct
should be performed. After placing a tie at the cystic–ductgall bladder junction, a small opening is made distally in the cystic duct, approximately 1 cm from its junction with the common
hepatic duct. A cholangiocatheter is inserted and secured with a 2-0
silk that is tied around the distal cystic duct containing the catheter (8).
After adequate cholangiography has been obtained, the cholangiocatheter is
removed, the cystic duct is doubly clamped and divided (9), and the gall
bladder is removed from the operative field.
9
Cystic duct
24 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
The cystic duct stump is then ligated with a 2-0 silk (10). Most surgeons continue to use
silk, as we do. Others are concerned that silk may act as a nidus for gallstone formation and
thus use a synthetic absorbable material. Clips may also be used. Clips are used routinely during laparoscopic cholecystectomy. The right upper quadrant is copiously irrigated with an antibiotic-containing saline solution, hemostasis in the bed of the liver is achieved with the electrocautery or argon beam coagulator, and the abdomen is closed (11). Most surgeons do not
leave a drain following a routine cholecystectomy. However, if the cholecystectomy was for acute
cholecystitis, or if there has been bile leakage from the gall bladder bed in the liver, leaving a
closed suction Silastic drain is appropriate.
10
Gall bladder
fossa
Cystic a. and
duct stumps
Common
hepatic duct
Many studies have shown drains to be
unnecessary following cholecystectomy.
The only reason for leaving a drain behind is if
an unexpected bile leak occurs from a small
unrecognized bile ductule in the bed of
the liver. Leaving a drain in place obvi-
ates the need for percutaneous
drainage if a biloma or abscess
occurs. Even though rare, it seems
to us that the discomfort of a
drain is worth the avoidance of
a potential biloma or subhepat-
ic abscess, in the face of acute
cholecystitis, or bile seeping
from the gall bladder bed in
11
the liver. If biliary drainage
does not occur within 48
hours, it can be removed, often
on an outpatient basis. There are
virtually no significant liabilities
from draining the operative site fol-
lowing elective cholecystectomy.
Common Duct Exploration
Operative Indications:
In the past, common duct exploration was a common procedure performed by general surgeons. Today it is only infrequently indicated. Most patients with common duct stones can be managed by endoscopic techniques. Endoscopic retrograde
cholangiography can delineate the anatomy, and following papillotomy, most stones can be endoscopically extracted from
the duct using balloons or baskets. Those that cannot be easily extracted generally pass spontaneously within the next few
days. Some patients are not candidates for endoscopic papillotomy. Patients who have had gastric resections with a Billroth
II reconstruction, generally are not candidates for endoscopic retrograde procedures on the biliary tree. Many of those
patients can be managed percutaneously and transhepatically with catheters, either pushing the stone forward through the
ampulla into the duodenum, or extracting them out a mature percutaneous tract. Occasionally, there will be patients who
are not candidates for either endoscopic or percutaneous procedures—who, at the time of open cholecystectomy, will have
indications for common duct exploration.
Operative Technique
The operation is generally performed through a right subcostal incision.
26 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Prior to performing a choledochotomy the duodenum is kocherized extensively (1). This allows one to palpate
the distal common duct as it passes
behind the first portion of the duodenum and the head of the pancreas, prior
to entering the distal second portion of
the duodenum through the ampulla. The
common duct itself is cleaned for a 2 cm
or 3 cm length, generally between the cystic
duct stump and the duodenum. Stay sutures of
5-0 synthetic nonabsorbable material are placed
in the common duct, and a choledochotomy is performed (2). The choledochotomy should be of ample
length, at least 1
1
⁄2 cm, to allow for easy instrumentation of the
Gall bladder fossa
Cystic a. and
duct stumps
Common duct
Pancreas
Kocherized
dudenum
1
duct without traumatic extension. Stones are often spontaneously
evacuated as bile issues forth from the common duct opening. At the same
time, any stones that are palpated in the distal common duct can be milked up
toward the choledochotomy and removed (3).
2
Cystic a. and
duct stumps
Choledochotomy
Common duct stone
3
There are a variety of instruments that one can utilize to
explore the biliary tree. Generally, we utilize all of these
instruments in an effort to completely rid the biliary tree of calculi. It is important that the choledochotomy be made adequate
in length, so that the instruments used to extract biliary calculi do
not traumatically extend the incision. A variety of scoops with malleable
handles can be used to pass distally down to the ampulla (4) and proximally up into the intrahepatic biliary tree via both the right and left
hepatic ducts. These scoops come in a variety of sizes and can be
extremely effective in removing small stones or biliary sludge.
Common Duct Exploration 27
4
Biliary scoop
Small stones
and sludge
Intrahepatic
stone
Randall stone forceps are also utilized (5), and many surgeons use these instruments ini-
tially in the duct exploration. These forceps come with a variety of curves that
range from almost straight, to right-angled and even acutely angled. These
instruments are very effective in grasping larger well-formed stones. The
biliary balloon catheter is particularly useful. It can be passed down
distally through the ampulla and then inflated to document patency
of the distal biliary tree into the duodenum. This is perhaps the
safest way to demonstrate an open ampulla. In using the balloon
5
catheter, one has to be careful that it is not overdistended.
Experimental studies have demonstrated intrahepatic ductal
disruptions and liver abscesses from overinflation of the
balloon. If one constantly moves the catheter back and
forth as the balloon is inflated, being certain that the
balloon catheter remains mobile within the ductal sys-
Randall Stone
forceps
tem, overinflation is unlikely.
28 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
The balloon catheter is particularly effective in retrieving intrahepatic stones (6).
One of the most effective maneuvers in ridding the biliary
tree of small stones and biliary sludge is irrigation using a small
catheter. A 12 French catheter placed intrahepatically into the
right and left hepatic ducts, together with large volume irrigation
6
with saline, is extremely effective in ridding the entire biliary tree
of small stones (7).
Irrigation catheter
7
Biliary balloon
catheter
This irrigation maneuver can also be carried out distally (8). Passage of the French catheter through the ampulla into the duodenum is also a safe way of demonstrating ampullary patency.
The use of Bakes dilators is controversial. Many
surgeons feel that the potential for creating false pas-
Common Duct Exploration 29
Irrigation catheter
8
sages, injuring the ampulla and/or initiating postoperative pancreatitis is so great that these metal dilators
should never be used. Other surgeons feel it is acceptable to carefully and gently utilize the smallest Bakes
dilators to demonstrate patency of the ampulla only, and
not for dilatation. Our philosophy is that it is easier to
demonstrate patency of the ampulla with either a balloon
catheter or a small French catheter. If neither of these is effective in
demonstrating patency of the ampulla, then very cautious and gentle use
of a small Bakes dilator is acceptable. Generally, the Bakes dilator passes gently through ampulla, and patency can be demonstrated by seeing the “steel grey” end of the dilator pressed against the lateral wall
of the duodenum (9). We feel that, only rarely, is there an indication
for the use of a Bakes dilator larger than 3 French.
Catheter tip
through ampulla
9
#3 Bakes
dilator
30 Atlas of Gastrointestinal Surgery: Gall Bladder and Biliary Tract
Dormia stone basket
At the end of the common duct exploration, after all the
10
Flexible
choledochoscope
maneuvers have been used to rid the biliary tree of stones,
many biliary tract surgeons prefer to perform choledo-
choscopy. There are many flexible fiber optic instruments
that can be used. Many studies have demonstrated that
operative choledochoscopy significantly lowers the inci-
dence of retained common duct stones. Using a flexible
choledochoscope allows the surgeon to visualize the entire
extrahepatic biliary tree, and a large portion of the intrahep-
atic biliary tree. With a choledochoscope one can utilize bal-
loon and basket catheters to retrieve visualized stones (10).
Tailored T-tube
11
Following completion of the common duct exploration, routinely, a T-tube is inserted. Our preference is for the variety of T-tube with a larger diameter external limb and
a small diameter T. We further decrease the size of the T by cutting off the back wall.
A wedge should also be removed (11) from the back wall to allow collapse of the
two T limbs when the T-tube is removed.
Following insertion of the T-tube, the choledochotomy is closed
with either continuous or interrupted sutures (12). Many surgeons
feel that synthetic absorbable material, either 4-0 or 5-0, should be
utilized to eliminate the theoretical possibility of a permanent suture
Common Duct Exploration 31
material acting as a nidus for stone formation. Others have utilized
synthetic nonabsorbable monofilament material without any obvious
adverse affects.
Closing cholangiography should be performed. If filling defects
(suggestive of stones that are so large that they probably will not pass
spontaneously) are seen, the duct exploration should be repeated.
Some feel that, if successful choledochoscopy has been performed, a
completion cholangiogram is not necessary. We feel, however, that a closing cholangiogram should always be performed. If contrast does not enter
the duodenum on cholangiography, glucagon should be administered to
relieve ampullary spasm.
The T-tube should be brought out laterally, without sharp turns or bends to
allow for easy instrumentation subsequently if a retained stone should be identified.
The T-tube should be firmly secured at the skin with two 5-0 stainless steel wire
Choledochotomy
closure
12
sutures. Bile-bag drainage via gravity should be established immediately. A closed suction
Silastic drain should be left in the area of the choledochotomy and T-tube exit site.