Case 13

Dictated by Donald E. Wenner, MD FACS

Sixty year old female presented with history of Laparoscopic Cholecystectomy 18 months ago in another NM hospital. She presented with signs and symptoms suggestive of retained CBD stones and a GI referral was made. Gastroenterology proceeded with ERCP and Sphincterotomy. A large stone was removed, but the duct could not be cleared, and a stint was inserted. Several weeks were allowed to pass and a second ERCP was done, but again there was no success in clearing the CBD. A large stone remained impacted in the distal bile duct and would not budge. A stint was reinserted and the patient was referred to me for LCBDE.

Adhesions from the previous surgery were lysed, and the CBD was identified. This was confirmed by aspirating the presumptive CBD with a 21 gauge scalp vein needle and obtaining bile. A dynamic fluoroscopic IOC was obtained through the scalp vein needle. This showed two large stones impacted in the distal CBD and sludge/debris in a dilated biliary system. (see attached cholangiogram) An 8 mm choledochotomy was made using a laparoscopic #12 bladed scaple. The MIG was inserted into the CBD. Excellent irrigation to distend the CBD was obtained by connecting a 15 G blunt needle to one of the two 1.9mm MIG channels. The flexible Choledochoscope (2.8 mm) was run down the 3.5mm large MIG channel and the CBD stones and stint were visualized. I had expected that I would need the laser lithotripter to break up these large stones, but with irrigation and minimal manipulation with a balloon catheter the stones floated free and presented themselves at the choledochotomy where they were easily removed. The bile duct was re-inspected both proximally and distally. The choledochoscope advanced easily through the ampulla into the duodenum. The stint was still in place. It was elected to close the choledochotomy primarily, and this was done using interrupted Vicryl sutures.

Post-operatively, there was no bile leak. There was no bounce in the amylase, and the patient has recovered and gone home. She will need to return in 3 weeks to have the stint removed. The entire procedure time was just under 2 hrs.