Dictated by Donald E. Wenner, MD FACS
A 56 YO female presented with cholelithiasis and biliary colic. Pre op Lab data showed bili of .6, SGOT 17, SGPT 11, Alk phos of 108 and amylase of 26. WBC was 8800. The patient had a history of a two unit bleed into her back from a spinal anesthetic in the past. She was severely obese. A hematology work up preoperatively revealed Von Willibrand’s disease and platelet dysfunction. Per hematology recommendations she was transfused 6 units of platelets immediately pre-op.
At surgery her routine IOC demonstrated six stones in the distal CBD. The cystic duct was large enough to permit the introduction of the 2.8 mm choledochoscope. This was deployed via the MIG through the 10mm epigastric port into the cystic duct. Upon choledochoscopy many stones were encountered in the CBD, around 15 – 20 in all. A decision was made to persist with the cystic duct LCBDE approach, feeling that in this patient with a bleeding disorder, this approach was preferable to a choledochotomy approach which would have likely been faster, but required additional dissection or a two stage approach with ERCP/ sphincterotomy. Using a 120 cm nitinol tipless stone basket, all of the stones were retrieved through the cystic duct. These were deposited on the peritoneum for later retrieval. The post of cholangiogram was clear. The cystic duct was ligated, and the cholecystectomy completed. The post op course was uneventful.
Operative time was 196 minutes, owing in large part to the large number of stones in the bile duct. It amazed me how badly the IOC underestimated the number of stones in the bile duct. It is also noteworthy how the pre op lab gave no hints to the presence of choledocholithiasis. The patient’s recovery went essentially like any routine lap chole. No drains were used and the following day her amylase was 34. Her very smooth post op course validated our choice to pursue the trans-cystic duct LCBDE approach.