Always (GL):
- teaching purposes, keep laparoscopic skill set up
On Demand:
- ....
Cameron:
- if CBD stones seen on cholangiogram:
- if <2mm try flushing with saline +/- IV 1-2mg glucagon
- if >2mm, will the stones pass on their own? <3mm and unable to flush stone out
- +/- post-op ERCP
- when should laparoscopic CBD exploration or open CBD exploration be performed?
- >3mm
- or do you arrange post-op ERCP?
Laparoscopic CBD exploration options - transcystic:
- wire and fogarty balloon flushing
- laparoscopic choledochoscopy
- Laparoscopic choledochotomy is much harder and depends on amount of inflammation
- unlike open CBD exploration, stay sutures are no needed
- choledochoscope is passed through mid-clavicular line 5mm port site
- choledochostomy closed over T-tube although primary closure has also been described
Open CBD exploration:
- lateral stay sutures
- 11 blade to open CBD longitudinally about 1.5 cm.
- the further distal the better so that you are away from the confluence of the hepatic ducts
- options include: choledochoscope, flushing, fogarty balloon, randall forceps followed by flushing, bakes dilators
- closure of CBD is usually done over a 14Fr T-tube which is left in for ~3 weeks. + JP in hepatic bed
- manage by doing a choangiogram then clamp T-tube. IF no leak in JP then pull JP prior to discharge
- leave in for 3 weeks and pull T-tube in the office (+/- another cholangiogram in the office)
Cameron:
- if CBD stones seen on cholangiogram:
- if <2mm try flushing with saline +/- IV 1-2mg glucagon
- if >2mm, will the stones pass on their own? <3mm and unable to flush stone out
- +/- post-op ERCP
- when should laparoscopic CBD exploration or open CBD exploration be performed?
- >3mm
- or do you arrange post-op ERCP?
Laparoscopic CBD exploration options - transcystic:
- wire and fogarty balloon flushing
- laparoscopic choledochoscopy
- Laparoscopic choledochotomy is much harder and depends on amount of inflammation
- unlike open CBD exploration, stay sutures are no needed
- choledochoscope is passed through mid-clavicular line 5mm port site
- choledochostomy closed over T-tube although primary closure has also been described
Open CBD exploration:
- lateral stay sutures
- 11 blade to open CBD longitudinally about 1.5 cm.
- the further distal the better so that you are away from the confluence of the hepatic ducts
- options include: choledochoscope, flushing, fogarty balloon, randall forceps followed by flushing, bakes dilators
- closure of CBD is usually done over a 14Fr T-tube which is left in for ~3 weeks. + JP in hepatic bed
- manage by doing a choangiogram then clamp T-tube. IF no leak in JP then pull JP prior to discharge
- leave in for 3 weeks and pull T-tube in the office (+/- another cholangiogram in the office)
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