Dictated by Donald E. Wenner, MD FACS
81 year old female with long history of gallstones and a history of intermittent jaundice. Presenting abnormal laboratory findings showed a bilirubin of 2.1, Alk. Phosphatase 376, SGOT 73, SGPT 83, GGT 532, and Ca 19-9 1150. CT scan showed cholelithiasis, choledocholithiasis, dilated intra and extra hepatic bile ducts, and normal appearing pancreas. ERCP with papillotomy was done, however the stones in the CBD were too large to be extracted, and several balloons were ruptured in attempt to dislodge them. The papillotomy was enlarged, but still the stones could not be removed.
The patient was taken to surgery the following day and underwent laparoscopic cholecystectomy and LCBDE using the MIG and the 2.8mm choledochoscope. The CBD was huge. The stones were multiple and greater than 2.0cm in diameter, as well as being fibrin embedded. The choledochotomy was much larger than the diameter of the MIG, and adequate distension to the CBD was problematic. The lithotriptor would have been useful, but was out for repair and unavailable. The smaller stones were removed with balloon catheters and irrigation. The largest fibrin embedded stone was eventually ensnared in the looping coiled-up balloon catheter and extracted. The proximal and distal CBD was thoroughly inspected by the MIG and choledochoscope. A T-tube was placed within the CBD. The patient made a smooth recovery and was discharged on postoperative day 4. Follow up T-tube cholangiogram showed the biliary tree to be free of stones. The T-tube was removed four weeks postoperatively, and the patient made a good recovery. Operative time 4' 23".