Case 8

Dictated by Donald E. Wenner, MD FACS

49 year old male presented with history of biliary colic and intermittent jaundice. An ultrasound showed sludge in the gallbladder versus small stones. Liver function tests were intermittently elevated with bilirubin up to 6.7, SGOT 300, and SGPT 488. Amylase was nl. Bilirubin direct was 6.4. These improved to bilirubin total of .6 preoperatively. The patient was taken to surgery at an ambulatory surgery center, where he underwent laparoscopic cholecystectomy with intraoperative cholangiogram (LCw/IOC). The cholangiogram demonstrated two stones in the distal CBD, and two stones in proximal common hepatic duct. A LCBDE using a choledochotomy technique was used. These stones were not impacted, and were dislodged with balloon catheters. The MIG with choledochoscope was used to inspect both proximal and distal bile ducts. Fairly marked inflammation of the distal duct and ampulla was seen, and it was elected to place a T-tube. Follow up T- tube cholangiogram one month later showed the biliary system to be free of any retained stones. The T-tube was removed. Patient has made a full recovery and remained an outpatient. This is the most cost effective approach to this clinical problem.

Discussion:

Outpatient LCBDE is feasible. Outpatient LCw/IOC is now a well established procedure. When stones are found they should be remedied by LCBDE at the time they are discovered. This is not an automatic reason for hospitalization. This case demonstrates non-impacted stones that were easy to remove with a balloon catheter via a choledochotomy. This case with common hepatic duct stones would not have been amenable to LCBDE using a cystic duct approach. The plug system was used to occlude the two smaller MIG lumens to prevent loss of pneumoperitoneum. The choledochoscope occupied the largest lumen of the MIG. A 3.2mm choledochoscope was used in this procedure.