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138
Fig. 5.4.2 a−d Standard papillotomy procedure.
a The Erlanger papillotome is advanced deep into the bile duct. Its posi-
tion is then confirmed by instilling contrast material.
5.4 Intraluminal Endoscopic Common Bile Duct Exploration and Stone Retrieval
b Then withdraw the papillotome until about half of the cutting wire
projects from the papilla. Slight tension is applied to the wire next.
Confirm proper position of the cutting wire before firing the instrument.
c d
Fig. 5.4.2c, d These endoscopic images demonstrate the optimal cut-
ting direction at 11 o’clock. The papilla is divided gradually with short
bursts of current. The surgeon should make sure that the wire is only in
contact with the roof of the papilla. Lifting the papillotome with the Albar-
ran lever places the required tension on the structure. The papilla only
Step-by-Step Procedure (Fig. 5.4.2a−d)
1. Determine diagnosis and indication for endoluminal procedure
by ERCP.
2. Advance the papillotome into the common bile duct.
3. Withdraw the papillotome until about half of the cutting wire is
visible.
4. Apply slight tension to the cutting wire in the 11 o’clock to
12 o’clock position.
5. Cut gradually in short electrocautery bursts.
should be incised; the incision ends approximately 1 mm before the junction with the wall of the duodenum. The incision is extended to include
the sphincter of the common bile duct only when extracting large stones
since this procedure increases the risk of bleeding and perforation.
Standard Procedure (Erlanger Method)
139
a b
c d
Fig. 5.4.3 a−d “Precutting” technique. This is used when the papillo-
tome cannot be advanced into the bile duct, as can occur in the presence
of a papillary stenosis.
a and b The “precut” papillotome has a short tip so that the cutting wire
easily comes in contact with the pore of the papilla. The roof of the
papilla is incised from the ostium at 11 o’clock in an eccentric direction
to gain access to the bile duct. The incision is generally only 1−2 mm
along. After the papillotome has been advanced, the papilla can be
divided completely in the normal manner.
c The endoscopic image shows how only the tip of the papillotome can
be inserted as it is held back by the rigid pore of the papilla. Operating
the Albarran lever incises the arch of the papilla with the forward section of the wire. Repeat the attempt to advance the papillotome into
the bile duct after each incision.
d The complete papillotomy is performed according to the standard pro-
cedure.
140
5.4 Intraluminal Endoscopic Common Bile Duct Exploration and Stone Retrieval
Fig. 5.4.4 After papillotomy, every attempt should be made to extract all
stones to avoid retained debris, calculi, and cholangitis. Small or soft
stones can be removed with the balloon catheter (7 French, balloon
volume 2−3 ml).
Step-by-Step Procedure (Fig. 5.4.4 and 5.4.5)
1. Determine diagnosis and indication for papillotomy by ERCP.
2. Perform the papillotomy.
3. Extract the stones by ascending the extrahepatic biliary tree.
Extract smaller and softer stones with the balloon catheter,
larger stones with the Dormia basket.
4. For large stones that cannot be extracted, use mechanical
lithotripsy (if indicated, laser or electrohydraulic lithotripsy may
be also used if the necessary instruments and expertise are
available).
5. If intraluminal lithotripsy is unsuccessful, extracorporeal shockwave lithotripsy (ESWL) is indicated, if available.
6. Confirm absence of stones with endoscopic retrograde cholangiography (ERC) after completing a given procedure.
Bleeding: The surgeon should attempt to control bleeding endoscopically, for example with application of fibrin glue. If endoscopic methods are unsuccessful, superselective arterial embolization if readily available may be attempted before re-
sorting to open operative treatment.
Fig. 5.4.5 Dormia baskets are better for larger stones (5−7 French,
basket size 3−4 cm). The catheter is advanced into the bile duct with the
basket collapsed. The basket is then opened beyond the stone. The surgeon then moves the basket back and forth to capture the stone and extract it. To avoid impingement, extract the stones one by one progressing
from the distal to the proximal biliary tree.
Impacted basket: The method of choice is mechanical lithotripsy.
If this is unsuccessful, open intervention is indicated.
Basket breaks off of catheter: Extract basket with grasper.
Impacted stone: This complication generally occurs following
mechanical lithotripsy,particularlywhenthe distal common bile
duct is relatively narrow. In such cases, placement of a nasobiliary tube or biliary stent is recommended. Usually the stone fragments can be completely extracted within about a week after the
swelling has gone down.
Late Complications
After endoscopic division, the papilla will usually remain open
permanently. The loss of sphincter function necessarily results
in ascension of gas and duodenal contents into the bile ducts.
Gas in the biliary tract is therefore a typical radiological symptom following endoscopic papillotomy. Long-term results have
shown that late endobiliary morbidity is relatively rare. To date
there has been no evidence of negative consequences of accelerated enterohepatic circulation.
Cholangitis: This occurs as a complication following endoscopic
treatment when drainage is impaired, as can happen with recurring stones or ductal stenosis.
Standard Procedure (Erlanger Method)
a
141
b
Fig. 5.4.6a, b Mechanical lithotripsy with the endoscope in place. If a
stone is too large to be extracted, intraluminal lithotripsy is first attempted. A special Dormia catheter is used for endoscopic lithotripsy. This
means that the original Dormia basket must first be removed. If one is un-
successful in shaking the stone out of the basket, push it back as far as the
bifurcation. As the basket is opened, it is pushed into one of the hepatic
ducts. Since the stone is generally larger than the lumen of the hepatic
duct, it will fall out of the basket. The basket can then be closed in the he-
patic duct and withdrawn.
Recurrent gallstones: True newly formed gallstones are pri-
marily pigment stones. The incidence of this complication is 1−
2%.
Most recurrent gallstones come from a gallbladder left in place.
Cholecystitis: As a general rule, an interval cholecystectomy
should be performed after endoscopic endoluminal extraction
of biliary tract stones. If the gallbladder with gallstones is in-
operable (mostly because of a general condition), the risk of
later complications must be accepted. The risk of cystic duct
stone incarceration increases with decreasing stone size. In a
Fig. 5.4.7 A 5−7 French 300-cm Teflon pigtail catheter is used as a nasobiliary tube. A flexible 0.035-inch guide wire is required to straighten the
tip. The catheter is placed in the bile duct in the usual manner, after which
the wire can be removed. As the catheter is advanced, the endoscope is
slowly withdrawn. The bile duct catheter is drawn out through the nose
with the aid of a second soft tube.
three-year observation period, this risk was assessed at about
1% in our experience.
Papillary stenosis: Stenosis due to scarring only occurs after an
incomplete incision.
142
5.5 Common Bile Duct Exploration and Stone Removal
5.5 Common Bile Duct Exploration and Stone Removal
F. Götz, A. Pier
Goals and Methods
Gallstones occur simultaneously in the gallbladder and bile
ducts in about 15% of all patients. The tentative diagnosis of bile
duct stones is made on the basis of patient history and clinical
findings of obstructive jaundice (clinical picture of cholestasis).
Ultrasound is the procedure of choice in arriving at a preoperative diagnosis; cholangiography and endoscopic retrograde
cholangiography (ERC) are also used for this purpose. These
procedures can also be of great help intraoperatively, as is
choledochoscopy. Treatment may include surgical removal of
stones via choledochotomy, or retrograde, intraluminal endoscopic management (generally but not necessarily including
papillotomy).
Known complications of papillotomy include bleeding and per-
foration. No long-term studies are yet available on the clinical
significance of reflux due to sphincter relaxation.
Indications
A clinically proven method is to remove the stones via trans-
papillary retrograde endoscopy in a first step and then perform
a cholecystectomy in a second independent procedure. The
order of the procedures may be reversed when the surgeon un-
expectedly encounters bile duct stones intraoperatively during
a laparoscopic cholecystectomy, currently the procedure of
choice.
If clinical conditions are not favorable to removing bile duct
stones by preoperative or postoperative transpapillary retro-
grade endoscopy, the experienced laparoscopic surgeon may re-
move the stones during cholecystectomy through the dilated
cystic duct in a variety of very sophisticated transcystic ways.
This requires clear anatomy (i. e., the clear identification of the
hepatic duct and the common bile duct) and clear evidence or
justified suspicion of bile duct stones. If extraction is unsuccess-
ful, the experienced laparoscopic surgeon may expand the pro-
cedure and perform a choledochotomy as a last resort. The la-
paroscopic surgeon may use electrohydraulic lithotripsy or
pulsed-dye laser lithotripsy to fragment stones within the duct.
After removing the stones, some surgeons place a T-tube. If the
duct is cleaned of stones, this tube may be omitted.
Laparoscopic choledochotomy is a complex procedure that re-
quires extensive experience in laparoscopic surgery. In view of
the risks involved, it is not yet recommended as a standard pro-
cedure. When in doubt or if difficulties are encountered, the
surgeon is best advised to rely on choledochoscopy or, better
yet, intraoperative transpapillary retrograde endoscopy. Where
intraluminal endoscopy is not feasible, the surgeon must either
refer the patient to a properly qualified and equipped endoscopic facility or convert to an open procedure, depending on
the acuteness of the need for treatment. If any problems are en-
countered, immediate conversion to an open procedure is indi-
cated.
Bile duct stones in the presence of purulent cholangitis represent another problem. This threatening clinical syndrome re-
quires treatment by transpapillary retrograde endoscopy to re-
move the stones accompanied by transpapillary nasobiliary
suction and irrigation and intravenous administration of antibi-
otics. If necessary, the bile duct is treated in the traditional manner after the infection subsides.
Contraindications
쐌 Unclear anatomy.
쐌 Uncertain diagnosis in the presence of obstruction.
쐌 Stricture from suspected tumor.
Surgical Risks and Patient Information
If laparoscopic biliary surgery is contemplated during cholecystectomy because of the presence of bile duct stones, the patient
should be informed of possible complications (ocurring in
about 6−8% of patients) which would require conversion to an
open procedure or aborting the operation and planning for an
alternate approach later.
Tears and perforations of the bile duct are possible, including
the poorly accessible retroduodenal segment of the common
bile duct. The common bile duct suture that secures the T-tube
and closes the duct can fail. A stone basket can b ecome impacted in the duct or break off. In 5% of all cases, biliary duct
surgery is unsuccessful. These statistics should warn the inexperienced laparoscopic surgeon to avoid choledochotomy.
Special Preparations
쐌 Gastric tube.
쐌 Indwelling urinary catheter.
쐌 Ultrasound scan.
쐌 Intravenous cholangiography or ERC.
쐌 Gastroendoscopy or MDP to exclude pathologic tissue
changes in the stomach and duodenum.
쐌 CT scan if a tumor is suspected.
Alternate Procedures
쐌 Preoperative intravenous or oral cholangiography and in-
traoperative ERC.
쐌 Preoperative and intraoperative ERC.
쐌 Preoperative and intraoperative transhepatic cholangiogra-
phy.
쐌 Intraoperative choledochoscopy.
쐌 Intraoperative ultrasound (currently being tested).
Anesthesia
See chapters 2.5 and 4.1.
Complications
143
Positioning
See chapter 4.1
Position of Operating Team
See chapter 4.1.
Trocar Placement
(See Fig. 4.1.28).
The usual trocar placement can be supplemented by inserting
an additional 10-mm instrument trocar between ports T2 and
T3. Open trocar placement is an alternative (see chapter 2.2).
Complications
Intraoperative Complications
Avulsed stone basket
Corrective action: Endoscopic extraction. If this is unsuccessful,
conventional choledochotomy is indicated.
Bleeding
Bleeding from the wall of the common bile duct when using
electrohydraulic lithotripsy.
Corrective action: Generally the bleeding stops spontaneously.
If this is not the case, control bleeding by endoscopic coagula-
tion or local chemical or mechanical means. If this is unsuccessful, conversion to open laparotomy is indicated to control bleeding.
Bile Duct Injury
Choledochoscopy can result in a perforation of the bile duct,
particularly in the retroduodenal part (see Fig. 5.2.5). When the
approach is through the cystic duct, the posterior wall of the
common bile duct is at risk for perforation.
Corrective action: Visualize the defect endoscopically through a
transpapillary approach, and repair it conventionally.
Difficulties in Extracting Stones in the Common Bile Duct
Corrective action: If endoscopic lithotripsy (mechanical, pulsed-
dye laser, or electrohydraulic) is unsuccessful, conversion to an
open procedure is indicated.
Late Complications
The same complications may occur as after laparoscopic
cholecystectomy (see chapter 4.1). Impaired passage in the
common bile duct is diagnosed clinically and endoscopically,
and is treated endoscopically where possible. If this is unsuccessful, open laparotomy is indicated.
Step-by-Step Procedure
I Technical preparations
See chapter 4.1.
Additional preparations:
Prepare for intraoperative cholangiography (select catheter and
contrast material, etc.).
Prepare choledochoscope with operating channel, stone basket,
and balloon catheter.
II Establishing the pneumoperitoneum
See chapter 4.1.
III Laparoscopy
See chapter 4.1.
IV a Fluoroscopic and endoscopic transcystic bile duct procedure
1. Introduce stone basket through the cystic duct.
2. Entrap stones under fluoroscopic control.
3. Place cystic duct drainage tube.
4. Verify proper drain placement with fluoroscopy.
or:
1. Introduce choledochoscope with operating channel.
2. Inspect common bile duct.
3. Entrap stones under endoscopic visualization with stone basket
and balloon catheter.
4. Place catheter drain through the cystic duct.
5. Verify proper drain placement with fluoroscopy.
IV b Choledochotomy
1. Make 1.5−2-cm incision in the common bile duct inferior to the
junction with the cystic duct.
2. Inspect the biliary system with choledochoscopy.
3. Introduce a stone basket through the operating channel of the
choledochoscope to entrap bile stones under endoscopic vision.
4. Place T-tube drain.
5. Close the choledochotomy with three or four interrupted sutures. Use absorbable suture material 4 × 0, metric 1.5 (see
chapter 2.2 for technique).
6. Continue laparoscopic cholecystectomy (see chapter 4.1).
Immediate Postoperative Complications
Some of the same complications may occur as after a laparoscopic cholecystectomy (see chapter 4.1). Complications
specific to endoscopic transcystic biliary surgery (such as dislo-
cation of the T-drain, difficulties in removing the drain, and retained bile duct stones) are treated appropriately, as indicated
by the specific complication and based on the experience of the
team with either a primary endoscopic or open operation or
even sequential endoscopic/open procedure.
Bilirubin levels may transiently increase following intracorporeal lithotripsy. This symptom will subside within a few days
when a spasmolytic agent is administered.
144
5.5 Common Bile Duct Exploration and Stone Removal
Operative Techniques
2
T3
1
T2
a b
Fig. 5.5.1 a,b Common bile duct exploration and stone removal. Entry
through the stump of the cystic duct.
Transcystic exploration of the extrahepatic biliary system begins by introducing the choledochoscope through a transverse incision in the cystic
duct (a). Ligate the cystic duct near the gallbladder or close it with a clip as
shown here. Then grasp the gallbladder at the infundibulum and retract it
laterally (port T3). Applying tension in this manner exposes the ductal sys-
tem with the dissected cystic-common duct confluence. If the cystic duct
is too small, dilate it with a balloon catheter (b) inserted through port T2.
2
3
1
T2
3
This is generally sufficient to extract stones up to 6 mm in diameter. Insert
a flexible choledochoscope through the transverse incision for direct endoscopic inspection. We recommend using a choledochoscope with a deflectable tip. An alternative is to entrap the stones with a stone basket
under fluoroscopic inspection.
1 Cystic duct
2 Common hepatic duct
3 Common bile duct
T3
T2
Fig. 5.5.2 Common bile duct exploration and stone removal. Longitudinal incision of the common bile duct.
The gallbladder is removed as previously described. The presence of bile
duct stones is confirmed by intraoperative cholangiography (see chapter 5.2).
Using mini dissection scissors inserted through the instrument trocar at
port T2, incise the common bile duct longitudinally near the ligated
stump of the cystic duct (dashed line). Make the incision about 1.5 cm
long as in a conventional operation. Minor bleeding usually stops without
requiring treatment. To improve visualization of the surgical site, retract
the bed of the gallbladder superiorly toward the diaphragm with a grasper
(port T3). Position the patient in a reverse Trendelenburg position with
the table steeply inclined to the left. This shifts the intestines and left hepatic lobe and provides better exposure of the surgical site. Caution: The
operating table must be equipped with a thorax cushion.
Where indicated, conventional biliary surgical technique may be employed with placement of a T-tube drain. If the bile ducts and papilla are
free of stones, the T-tube drain may be dispensed with.
T3
T2
Complications
1
2
145
Fig. 5.5.3 Common bile duct exploration and stone removal. Intraopera-
tive choledochoscopy.
The commercially available choledochoscopes permit the surgeon to visu-
alize the common bile duct or the common hepatic duct as far as the bi-
furcation (Fig. 5.5.4). Advance the choledochoscope toward the papilla to
verify that the common bile duct is free of stones.
Fig. 5.5.5 Common bile duct exploration and stone removal. Choledo-
choscopic stone extraction with a stone basket.
A flexible choledochoscope with an axial operating channel and de-
flectable tip inserted through port T2 permits visualization of the bile
ducts (insert shows stone). The surgeon can extract stones with a stone
basket; a balloon catheter may also be used (see Fig. 5.5.8 a−d).
Fig. 5.5.4 Common bile duct exploration and stone removal.
Intraluminal image of the bifurcation of the common hepatic duct viewed
through a flexible choledochoscope.
1 Right hepatic duct
2 Left hepatic duct
T2
146
5.5 Common Bile Duct Exploration and Stone Removal
T3
T2
Fig. 5.5.7b Common bile duct exploration and stone removal. Balloon
catheter and stone basket.
The wall of the duct is dilated by inflating the balloon catheter. Use the
space created between the stone and the ductal wall to advance the
basket past the stone. You can now entrap the stone and perform mechanical lithotripsy.
Fig. 5.5.6 Common bile duct exploration and stone removal. Placing a T-
tube common duct drain.
After completing an extrahepatic biliary operation and stone extraction
(see Figs. 5.5.3 to 5.5.5), place a T-tube drain with its branches, notch,
etc. prepared in the usual manner.
Introduce the drain into the abdomen through the right paramedian in-
strument trocar using an instrument tube (port T2). Insert the inferior
arm into the common bile duct with a grasper (port T3). Because of the
shape and flexibility of the drain, you can usually insert the second arm
into the common hepatic duct relatively easily.
After verifying that the drain is properly seated, close the incision with
two or three interrupted sutures (absorbable suture 2/3 × 0; see
Fig. 5.5.7). Test the T-tube drain (terminated extraabdominally) for leaks
by injecting saline solution and verify proper seating again with fluoros-
copy. The sutures may be sealed with fibrin glue.
Fig. 5.5.7c Common bile duct exploration and stone removal. Mechanical lithotripsy.
After dilating the duct with the balloon catheter, advance the axial stone
basket to entrap and crush the stone. Lithotripsy may be performed as a
transcystic procedure or through a choledochotomy. Monitor the operation with fluoroscopy.
Fig. 5.5.7a Common bile duct exploration and stone removal. Balloon
catheter and stone basket.
In addition to extraction in a stone basket under fluoroscopic control (see
Fig. 5.5.5), bile duct stones can be extracted endoscopically. Advance a
balloon catheter that can accommodate a stone basket under fluoro-
scopic control up to the stone.
Fig. 5.5.7d Common bile duct exploration and stone removal. Balloon
catheter and stone basket.
Once the duct has been dilated with the balloon catheter, the catheter
can be advanced past the stone. By withdrawing the catheter with the balloon inflated, you can extract a stone transcystically or through a choledochotomy. Other options include electrohydraulic lithotripsy or Nd:YAG
pulsed-dye laser lithotripsy.
Fig. 5.5.8 Common bile duct exploration and stone removal. T-tube
drain.
T-tube drain is placed and secured with interrupted sutures (absorbable
place a drain anterior to Winslow’s foramen (see Fig. 4.1.50).
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