Case 14

Dictated by Donald E. Wenner, MD FACS

59 YO male s/p laparoscopic cholecystectomy two years previously, no cholangiogram done at time of initial surgery. Symptomatically he did not improve, and this eventually led to further evaluation. An ERCP documented choledocholithiasis, and a sphincterotomy done. This procedure was complicated by bleeding from sphincterotomy. A biliary stint was placed. A second ERCP was done 1 month later. Balloon sweep of CBD dislodged two stones; however one large stone remained, and it became impacted in ampulla. The sphincterotomy was enlarged, however brisk arterial bleeding encountered. This was controlled with epinephrine injection. The stint was replaced, procedure terminated and surgical consultation requested.

A LCBDE procedure was done. The CBD was identified. Confirmation of ductal anatomy was obtained by using a scalp vein needle to puncture the CBD and contrast injected for DFIOC. A choledochotomy was made using a laparoscopic scalpel with a #12 blade. The MIG, set up with irrigation via a 15G blunt needle through one of the two small channels, and the 2.8 mm choledochoscope, was used to guide the choledochoscope into the CBD via the choledochotomy. A large stone was visualized in the distal CBD. A nitinol stone basket was deployed, and the stone engaged in the basket under video guidance. The MIG, choledochoscope and stone were removed from the choledochotomy. The choledochoscope was then passed across the ampulla into the duodenum. The bile duct was inspected as the choledochoscope was withdrawn. The stint was found displaced into the CBD, and was removed via the choledochotomy. The proximal duct radicals were inspected and found clear of stones. The choledochotomy was closed primarily, and a JP drain placed in the subhepatic space.

This case shows LCBDE using the 2.8mm choledochoscope and MIG to be successful in a patient with previous laparoscopic cholecystectomy, and failed ductal clearance after two ERCP/ sphincterotomy attempts.