Case 3

Dictated by Donald E. Wenner, MD FACS

86 year old female presented with RUQ abdominal pain, positive Murphy's sign, nausea and vomiting. Laboratory studies showed bili 3.6, alkaline phosphatase 200, SGPT 41, SGOT 41, WBC 6,600. Ultrasound showed cholelithiasis, mild thickening of the gall bladder wall, and dilated CBD. The patient was taken to surgery for LC with IOC. Findings at operation were of severe acute cholecystitis, perforation of the gall bladder and two large stones impacted in the CBD. The stones were cleared from the bile duct using the MIG, a 3.2mm choledochoscope, electrohydraulic lithotriptor, balloon catheter, and irrigation catheter. The lithotripter fragmented the impacted stone; the second stone was dislodged with the balloon catheter. The lithotripter was deployed in the working channel of the choledochoscope, with the irrigation catheter in one of the small MIG lumens. The perforated, severely inflamed gall bladder was removed at the same operation. Operative time 3' 30". T-tube and drains were placed. The patient was treated with antibiotics and was discharged on postoperative day ten. T-tube cholangiogram taken four weeks postoperatively showed the CBD free of stones, and the T-tube was removed at that point. The patient has gone on to a full recovery.

Discussion:

ERCP and clearance of the CBD in this patient would not have taken care of the severely inflamed and perforated gall bladder. With LC and LCBDE the diseased gall bladder was removed and the bile duct cleared of stones and drained in a single operation. This is the most cost effective and reliable method of dealing with this patient's problem. CBD stones were large and impacted, and even in this difficult setting minimally invasive surgical techniques took care of her problem. The procedure was safe in this very frail elderly patient. The MIG protected the choledochoscope from damage with grasping forceps, and provided a way to deploy a choledochoscope, an electrohydraulic lithotripter, and an irrigation catheter into the bile duct simultaneously. There was no evidence for any postoperative pancreatitis.