Walter S. Cha

Introduction

Approximately 15% of patients with gallbladder stones will also have stones within the common bile duct (CBD). Currently, the majority of patients with CBD stones can be managed by using endoscopic techniques. However, endoscopic management of CBD stones may be problematic with multiple large stones or stones above a stricture, in young patients, and in patients with difficult access to the ampulla of Vater (prior gastrectomy or Roux-en-Y gastric bypass). Patients who are not candidates for endoscopic or percutaneous procedures may require surgical intervention. Surgical approaches to the CBD include laparoscopic CBD exploration through a transcystic approach or a choledochotomy, open CBD exploration, and biliary-enteric anastomosis.

Cystic Duct Anatomy and Variants

In most individuals (64% to 75%) the cystic duct joins the hepatic duct at approximately a 40-degree angle (Fig. 13-1). Less frequently (17% to 23%) the cystic duct runs parallel to the hepatic duct for a distance and may even enter the duodenum separately. In 8% to 13% of individuals the cystic duct may enter the hepatic duct on the left side after passing in front of or behind the common hepatic duct. Infrequently, the gallbladder may be sessile, with little to no cystic duct.

Laparoscopic Common Bile Duct Exploration

If CBD stones are identified at laparoscopic cholecystectomy, laparoscopic CBD exploration may be warranted (Fig. 13-2). Successful laparoscopic CBD exploration avoids the risks associated with deferring treatment of a CBD stone or a subsequent endoscopic procedure.

Trocar placement for laparoscopic CBD exploration is similar to the port configuration used during laparoscopic cholecystectomy. An additional port in the right upper abdomen may be used for the choledochoscope or catheters.

Transcystic Approach

The transcystic approach to CBD exploration avoids a choledochotomy and eliminates the subsequent need for a T tube. After controlling the cystic duct on the gallbladder side, a cystic ductotomy is created and a cholangiocatheter placed. The cystic duct may need to be dilated with a balloon before subsequent interventions to extract calculi (Fig. 13-3, A).

FIGURE 13–3 Transcystic and transductal/choledochotomy approaches.

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