Endoscopic, open and laparoscopic management of common bile duct stone. Detail management involving extensive description and important videos to clearly understand endoscopic, open surgical and laparoscopic approach. Very useful for surgery residents who want to know detail management of common bile duct stones. Various ERCP guided interventions. Relevant anatomy related to surgeon. Various approaches of surgery for common bile duct stone. Important with respect to various persons related to medicine and pateints.

1. PRESENTER: DR. RIZWAN KHAN
(PG 2nd YEAR)
GUIDE: DR. RAJESH LONARE
(HOD AND LAPAROSCOPIC SURGEON)
DR. RAHUL AGRAWAL
(ASSISTANT PROFESSOR AND ONCO SURGEON)
RKDF MEDICAL COLLEGE, BHOPAL

7.  Formed by union of cystic and CHD near
porta hepatis.
 5-12 cm in length and 6-8 mm in diameter.

9.  Supradudenal part (2cm) passes in free margin
of lesser omentum, to right of hepatic artery and
anterior to portal vein.
 Retrodudenal part (1.5cm) diverges laterally
from portal vein and hepatic arteries.
 Pancreatic part (3cm) curve behind head of
pancreas.
 Intradudenal part (1.1cm) runs obliquely within
wall of duodenum for 1 to 2 cm and open in
papilla of mucous membrane (ampulla of vater),
10 cm distal to pylorus.

11.  Sphincter of oddi, thick coat of circular
smooth muscle surround CBD at ampulla of
vater.
 4-6mm in length, basal resting pressure of 13
mmHg above duodenal pressure.
 Lined by columnar epithelium with numerous
mucous glands.

13.  Supradudenal part: liver (anteriorly), portal
vein and epiploic foramen (posteriorly) and
hepatic artery (left).
 Retrodudenal part: first part of duodenum
(anterior), inferior vena cava (posterior) and
gastrodudenal artery (left).
 Infradudenal part: posterior surface of head
of pancreas (anterior) and inferior vena cava
(posterior).

15.  Gastrodudenal and right hepatic arteries (lies
at 3 and 9 o’clock).

16.  Drains into portal vein.

17.  Upper part of bile duct drain into the cystic
node and to node on anterior border of
epiploic foramen. These are members of the
upper hepatic nodes.
 Lower part of bile duct drains into lower
hepatic and upper pancreaticosplenic nodes.

18.  Nerve supply: sympathetic (celiac plexus) and
parasympathetic (vagus).
 Parasympathetic nerves are motor to
musculature of bile ducts, but inhibitory to
sphincters.
 Sympathetic nerves are motor to sphincters.

19. PRIMARY
 Form in bile duct.
 Multiple, sludge like.
 Brown pigment stone (Calcium bilirubin).
 Associated with biliary stasis (defective
pathophysiology, choledochal cyst, biliary
strictures, papillary stenosis, tumors and
secondary stones) and infection.

20. SECONDARY
 Form within gallbladder and migrate into
CBD.
 Cholesterol stones / black pigment stones.

21.  Residual / retained bile duct stones: These are
one which is present in CBD within 2 years of
initial surgery – cholecystectomy. They are
usually missed secondary bile duct stones.
 Recurrent bile duct stones: These are one
which is present 2 years after initial surgery –
cholecystectomy and CBD exploration. They
are primary biliary stones.

22.  Biliary colic / severe spasmodic pain (right
hypochondrium).
 Referred pain (epigastric region through
vagus nerve or inferior angle of right scapula
through sympathetic nerves)
 Nausea and vomiting.
 Intermittent jaundice.
 Itching
 Dark urine
 Acholic stools

23.  Liver dysfunction and biliary cirrhosis.
 White bile formation and liver failure.
 Liver abscess.
 Suppurative cholangitis.
 Pancreatitis
 Septicaemia.

24.  Carcinoma of periampullary region (distal
CBD, 2nd part of duodenum and head of
pancreas).
 Biliary stricture
 Viral hepatitis

25.  Dilatation of gallbladder occurs only in
extrinsic obstruction of the bile duct like
pressure by carcinoma of head of pancreas.
 Intrinsic obstruction by stones does not cause
any dilatation because of associated fibrosis.

27.  Liver function test.
 Ultrasonography.
 Endoscopic Ultrasound.
 Computed tomography.
 MRCP (Magnetic ResonanceCholangio
Pancreatography)
 PTC (PercutaneousTranshepatic
Cholangiography)
 ERCP (Endoscopic RetrogradeCholangio
Pancreatography).
 Intraoperative diagnostic technique

30.  DilatedCBD (> 8mm in diameter).
 Advantages: non invasive, painless, no
radiation, can be performed on critically ill
pateints.
 Disadvantages: Depends on skills and
experience of operator, difficult in obese,
ascites and distended bowels, and
retroduodenal portion is difficult to visualise.

36.  Requires 30 degree endoscope with radial or
linear ultrasound transducer at tip.
 Intravenous sedation.
 Advantage: high resoulution images and
evaluate retroduodenal CBD.
 Disadvantage: operator dependent.

37.  CBD is 9 mm or more in diameter.
 Dense intraluminal calcification, or target
sign (halo of bile surrounding the higher
density stone).
 Advantages: high resolution and less time.
 Disadvantage: non visualisation of
cholesterol stones (blend imperceptibly with
surrounding bile).

40.  T2 weighted imaging.
 Advantages: high resolution anatomic
images and non invasive.
 Disadvantage: expensive and not readily
available.

41.  Puncture site: right midaxillary line below
ninth intercostal space.
 21- or 22- gauge, 15- to 20-cm styletted
needle is advanced under fluoroscopic
guidance over the rib.
 Water-soluble contrast agent is injected while
slowly withdrawing the needle until a bile
duct is identified.
 Radiographs obtained in multiple projections.

42. Filling defects
 Air bubbles: perfectly circular shape and
distribution in nondependent area.
 Calculous: faceted radiologic appearance and
move to gravity-dependent positions.
 Blood clot.

43. Complications
 Most common major complications are bile
leakage, sepsis and hemorrhage.
 Rarer complications include pneumothorax,
biliothorax, colon puncture, and abscess
formation.

48.  Side viewing gastroduodenoscope is used.
 Sedation like midazolam or propofol
anaesthesia.
 Patient is placed in prone position with head
turned towards right.
 After passing gastroduodenoscope, sphincter is
identified and cannulated.
 Under visualisation 3 mL of water soluble iodine
contrast is injected into bile duct and pancreatic
duct.
 Biliary and pancreatic trees are visualised. It is
done under C-ARM guidance.

49. Advantages
 Direct visualisation of ampullary region.
 Direct access to CBD for cholangiography or
choledochoscopy.
 Biliary sphincterotomy and stone extraction
can be performed.

50. RelativeContraindications
 Acute pancreatitis
 Previous gastrectomy

51. Complications
 Acute pancreatitis (octreotide prophylaxis,
gentle injection of contrast medium and
temporaray pancreatic duct stent).
 Asymptomatic transient amylasemia
(spontaneously disappears in 1 or 2 days).
 Post procedure cholangitis and bacteremia
(sterilization of endoscopic equipment and
prophylactic intravenous antibiotics that are
preferentially excreted from liver into bile).

52.  Bleeding.
 Perforation.

53. Causes of failure of ERCP
 Large stones (usually more than 2.5 cm).
 Altered gastric or duodenal anatomy such as
Roux-en-Y.
 Impacted stones.
 Intrahepatic stones.
 Multiple stones.

54. 1. Intraopeartive cholangiogram
Technique
 Gallbladder is retracted laterally, and cystic
duct and artery are cleared of the fat and
overlying peritoneum in area of triangle of
Calot.
 Small ductotomy (less than 50% of duct
circumference) is made in cystic duct
adjacent to gallbladder neck.

55.  Cystic duct is approached from right
subcostal or periumbilical port.
 60-cm, 5-Fr cholangio catheter is advanced
directly into cystic duct.
 Radiographic contrast is infused, and
fluoroscopic images are obtained.
 Complications: Ductal strictures and
pancreatitis.

56. 2. Intraoperative US.
3. Laparoscopic US:
 Imaged from right subcostal / periumbilical
port.
 Advantages: reduced risk of biliary and
vascular injury (Color flow images
distinguishing CBD from portal vein, identify
insertion of cystic duct into the CBD).

58.  Endoscopic sphincterotomy
 Endoscopic Mechanical Lithotripsy
 Endoscopic Laser Lithotrisy
 Endoscopic Electrohydraulic Lithotripsy
 Endoscopic DissolutionTherapy
 Endoprosthesis Placement

61.  Opening terminal part of common bile duct
or pancreatic duct by cutting papilla and
sphincter muscles.
 Incision is made at 12 o’clock position.
 Standard pull-type sphincterotomes allow
vertical incision to be made from papillary
orifice in a cephalad direction along the
intramural course of CBD.
 Incision is produced by controlled application

62. of monopolar electrocautery.
 Stone extraction from the CBD using Dormia
basket and Fogarty balloon.

64.  Dilation of sphincter muscle using high-
pressure hydrostatic balloons 6 or 8 mm in
diameter.
 Advantage: preservation of sphincter
function.
 Disadvantage: Limited size of papillary
opening. Stones measuring greater than 8
mm require mechanical lithotripsy to enable
transpapillary extraction.

67.  Baskets are sturdier and provide better
traction for removal of a larger stone.
 Balloon catheter occludes the lumen and is
ideal for removing small stones.

70.  Dormia basket is opened in CBD, and stone is
entrapped within braided wires.
 Stone is forcefully crushed in arms of Dormia
basket after entrapment.

71.  First generation laser system i.e.
neodymium:yttrium-aluminum-garnet
(Nd:YAG).
 Second generation devices based on pulsed
dye laser technology (xenon).
 Application of laser pulse leads to rapid
expansion and collapse of plasma on stone
surface, resulting in mechanical shock wave.

73.  Electrohydraulic probe consists of two
coaxially isolated electrodes at the tip of a
flexible catheter
 It delivers electric sparks in short, rapid pulses
leading to sudden expansion of the
surrounding liquid environment and
generating pressure waves that result in
stone fragmentation.

74.  Its main advantages over laser lithotripsy are
its lower cost and increased portability.

75.  Semisynthetic vegetable oil, monooctanoin,
(composed of 70% glycerol1-monooctanoate
and 30% glycerol-1,2-dioctanoate).
 Methyl tert-butyl ether (MTBE).
 Cholesterol solvents.
 Complication: Hemorrhage from duodenal
ulceration, acute pancreatitis, jaundice,
pulmonary edema, acidosis, anaphylaxis,
septicemia, and leukopenia.

78.  Two types of stents are used, made of either
plastic and expandable metal.
Technique
 After diagnosing site of the obstruction with
a diagnostic ERCP, small sphincterotomy is
performed to facilitate insertion of
instruments.
 Obstruction is negotiated with guidewire.

79.  Catheter is coaxially inserted.
 Stent is inserted using the Seldinger
technique.
 Decompression of obstructed biliary tree is
indicated by gush of dark stagnant bile into
duodenum.
Complications
 Stent clogging (replacement) and cholangitis.

80.  Acute hemorrhage (balloon tamponade,
direct bipolar electrocautery, washing area
with 1:10000 epinephrine solution,
application of hemostatic clips, laser
coagulation, superselective arterial
catheterisation and embolization an
infiltration with sclerosant).
 Acute pancreatitis (Gabexate, a synthetic
protease inhibitor, somatostatin, diclofenac
as rectal suppository).

81.  Acute cholangitis (adequate bile drainage
e.g., by nasobiliary catheter or
endoprosthesis, parenteral antibiotics)
 Perforation (percutaneous or surgical
drainage).

82.  Supradudenal choledochotomy
 T -Tube placement
 Transdudenal sphincteroplasty
 Biliary enteric drainage
(Choledochodudenostomy and
Choledochojejunostomy)

87. Indication
 Large or impactedCBD stones.
 Anatomic considerations that preclude
endoscopic treatment (prior gastric resection
and dudenal diverticula).
 who require open approach for
cholecystectomy (Mirizzi syndrome,
biliarenteric fistula, high suspicion for cancer,
and CBD stones demonstrated by palpation
or cholangiogram).

88.  Incision is same as Kocher’s incision.
 Pack should be put over hepatic flexure of colon
and medial part of dudenum and retracted.
 Lesser omentum and stomach are retracted
after placment of pack.
 Hepatic flexure is mobilised.
 Cephalad retraction of undersurface of liver
along base of segment IVb.
 Peritoneum on the anterior part of CBD is incised
to expose CBD for 2-3 cm.

89.  Two stay sutures are placed on CBD using 3-0
vicryl, one just above duodenum, another just
below level of joining of cystic duct.
 Stay sutures are placed on the anteromedial
surface of CBD.
 Incision is made vertically in CBD on its
anteromedial surface between stay sutures
for 1.5-2 cm using no. 15 blade.

90.  Any stones if felt is carefully milked upwards
towards choledochotomy wound.
 Stones are removed by different means—
pituitary scoop of proper size, Randall’s stone
forceps, Fogarty catheter, Dormia basket,
choledochoscope (ideal), Desjardin’s
choledocholithotomy forceps, Bake’s CBD
dilator (malleable no. 3).
 Choledochotomy is closed over T-tube (14-Fr
or larger).

91.  Fogarty catheter is negotiated into
duodenum and confirmed by feeling
duodenum.
 It is only partially inflated and allowed just to
pass through the ampulla proximally.
 Then it is fully inflated to gently pull upwards
towards choledochotomy to retrieve stone
along with that.
 Tube drain is placed at gallbladder bed .

92. Complications
 Post-operative pancreatitis due to CBD
perforation by forcible negotiation of tube
across ampulla into duodenum.
 Retained stone (irrigation of common bile
duct with saline via T-tube, ERCP and
endoscopic sphincterotomy, extracted via
dormia basket or balloon catheter).

93.  Postoperative bile leaks or biliary fistula
Waltman walters syndrome: upper
abdominal or chest pain, tachycardia and
persistent hypotension (place drain, plastic
endobiliary stent).

96.  Limbs of Kehr’s T Tube (16 Fr) should be
shortened.
 Each horizontal limb should be 1cm.
 Modified T-tube is held in Desjardin forceps,
and allowed it to be slipped into
choledochotomy.
 Interrupted 3-0 vicryl or 4-0 PDS is used.
 T-tube is brought out of the abdomen
through a separate stab incision at anterior
axillary line.

97.  T-tube cholangiogram is taken 14 days after
operation.
 Residual CBD stones are removed by: Dormia
basket, Fogarty’s catheter, Choledochoscope
or ERCP.
 If it appears normal, tube is removed on day
by gentle traction.
 In doubtful cases T-tube should be kept in
place for 21 days more.

98.  Often T-tube is clamped for 24 hours, if
patient develops, vomiting, pain abdomen,
bile leak from side of T-tube, it is probable
that there are retained stones.

99. Indication
 Stone is impacted at ampulla.
 Failure of endoscopic sphincterotomy.
 Papillary stenosis.
 Diverticula in dudenum.
Contraindication
 Long suprasphincteric stricture.
 Severe peiampullary inflammation.

103.  Kocher’s manoeuvre is done, common bile
duct is explored.
 No. 3 Bake’s dilator is passed into CBD but
not across the ampulla ofVater.
 Tip of dilator is palpated through anterior
duodenal wall which allows proper placement
of the sphincterotomy incision.
 Duodenotomy of 4 cm length is made in 2nd
part of duodenum centring at level of
ampulla.

104.  Retractors are placed into cut edges of
duodenotomy to expose the ampulla
adequately.
 It is better to place four stay sutures to retract
edges at four corners.
 Incision is made at 11 o’clock position. It keeps
incision away from pancreatic duct entry and
also is relatively avascular.
 Using no. 15 blade or Pott’s scissor, tip of Bake’s
dilator as a guide incision is made along orifice.

105.  After cutting partially, 4-0 vicryl sutures are
placed on either sides of opened ampulla and
held apart to give traction.
 Pancreatic duct orifice is identified at 5
o’clock position on posterior aspect. Incision
is further extended for 3 mm and additional
stay sutures are placed.
 Incision is continued sequentially every time
for 3 mm with a pair of vicryl stay sutures.

106.  Sphincterotomy of entire sphincter of Oddi
needs 2 cm length of incision along the ampulla.
Otherwise length of sphincterotomy should be
length of the CBD diameter.
 At the apex, figure of eight suture should be
placed.
 Choledochotomy is closed with a T-tube,
duodenotomy is closed and tube drain is placed.
 Abdomen closed in layers.

107. Complications
 Bleeding
 Subphrenic abscess formation
 Acute pancreatitis
 Cholangitis
 Sepsis
 Duodenal fistula
 Dehiscence of dudenal closure

108. Indications
 Multiple CBD stones.
 Large stone.
 Stones in dilated ducts.
 Irretrivable intrahepatic stones.
 Proven ampullary stenosis.
 Impacted ampullary stone.
 Diverticula in duodenum.

109. 1. CHOLEDOCHODUODENOSTOMY
 Pre requisite: CBD should be more than 1.5 cm.
Contraindications:
 CBD if not dilated significantly.
 Sclerosing cholangitis
 Chronic pancreatitis which needs surgical
decompression.
 Malignant obstruction
 Duodenal oedema.

110. Technique
 Kocherisation should be done.
 Longitudinal choledochotomy is made on CBD
of 2.5 cm in length.
 Duodenum is incised on its first part
longitudinally around 2.2 cm (3 mm lesser than
CBD incision).
 Distal end of choledochotomy is brought to
middle of lower leaf of duodenotomy.
 Stay sutures are placed using 3-0 vicryl.

111.  Further 3-0 vicryl interrupted sutures are
placed initially to complete the posterior
layer (knots should be outside ideally) then
anterior layer.
 Stoma should be at least 2.5 cm.
 Abdomen is closed with tube drain.

112. Complications
 Sump syndrome: it is due to creation of blind
segment / pouch at distal CBD causing stasis
and cholangitis.This pouch contains infected
bile, food, calculi.
 Bile leak due to anastomotic disruption.
 Recurrent cholangitis.

113. 2. CHOLEDOCHOJEJUNOSTOMY

114.  Jejunum is transected 25–30 cm distal to
duodenojejunal flexure.
 Distal end is brought up through window in
transverse mesocolon to the right of middle
colic vessels.
 End-to-side anastomosis of common hepatic
duct onto jejunum.
 Anastomosis is performed using single layer
of interrupted 4/0 PDS sutures.

115.  Anterior layer of sutures is passed from outside
to inside through bile duct.
 Needles are retained and they are held for
completion of these anterior sutures after back
of anastomosis has been finished.
 Anterior sutures are then elevated as retraction
to expose back wall of duct.
 Posterior sutures are all inserted, from inside to
out on the jejunum, and from outside to inside
on duct, but not tied.

116.  After all are in place they are held taut and
jejunum is ‘railroaded’ down into place and
the sutures tied.
 Front of anastomosis is then completed.
Needles are passed from inside to outside
through jejunum.
 When all sutures are completed, knots are
tied
 Enteroenterostomy is fashioned 70 cm distal
to this anastomosis.

119. Indications:
 stones that are multiple, large, or positioned
within the proximal bile ducts with CBD
diameter larger than 8 to 10 mm.
Procedure:
 10 mm laparoscope of 30° or 45° is used.
 Hepatoduodenal ligament is exposed. CBD is
lateral in hepatoduodenal ligament.

120.  Stay sutures are placed on either side of
midline of the CBD wall to allow anterior
traction on duct.
 Longitudinal 1-2 cm choledochotomy is made
on distal CBD.
 Placement of choledochoscope through
epigastric port.
 Stone forceps applied through 5mm
epigastric opening to remove stones.
 Stones extracted are placed in plastic bag.

121.  T-tube is placed in duct.
 Ductotomy is closed with fine absorbable
sutures using intracorporeal suturing
techniques.
 Continuous or interrupted absorbable 3.0 or
4.0 suture is used for closure.
 T-tube is exteriorized through lateral port
site.
 All trocar sites are closed.

122.  Patient is discharged after 2 to 4 days and
returns for T-tube cholangiogram and
removal ofT-tube at 14 to 21 days.

123. Complications:
 Laceration of CBD.
 Bile leakage (subhepatic drain is placed and
removed after 2–3 days).
 Sewn-in T-tubes, and postoperative CBD
strictures (because of inappropriate closure
technique or choledochotomy in CBD less
than 7 mm).