Case 6

Dictated by Donald E. Wenner, MD FACS

91 year old female presented with RUQ abdominal pain and nausea. Laboratory showed an elevated WBC of 15.4K, bili 2.7, alkaline phosphatase 267, amylase of 27, AST 79, ALT 118. Ultrasound demonstrated cholelithiasis, no CBD dilation. Patient was taken to surgery for LC with IOC. Cholangiogram demonstrated three large stones in an enlarged dilated CBD. The MIG and choledochoscope were advanced through an anterior choledochotomy. A balloon catheter was passed beyond the stones, and the stones were dislodged. The stones were too large to pass out the choledochotomy without extending the choledochotomy. The proximal and distal bile ducts were then inspected using the MIG and the choledochoscope. The bile ducts were clear. A T-tube was placed. The gallbladder was then removed. T-tube cholangiogram demonstrated the bile duct clear of stones, and good flow of contrast into the duodenum. The patient made a remarkable postoperative recovery and was discharged home on postoperative day four. The operation took 1' 52". There was no evidence of any postoperative pancreatitis.

Discussion:

Multiple large bile duct stones were removed using minimally invasive techniques on a 91 year old patient. The diseased gallbladder removed at the same operation. The MIG use again demonstrated to be safe. The choledochoscope was not damaged, and manipulation was facilitated by the MIG, controlling the scope until it was deployed into the bile duct.