Case 18

Dictated by Donald E. Wenner, MD FACS

A 53 YO female presented with acute cholecystitis with positive Murphy’s sign. Lab data showed bili 1.2, SGOT 13 SGPT 10, alkaline phosphatase 100, amylase 47, and WBC of 24400. Pre operatively, choledocholithiasis was unsuspected. At surgery, the patient had acute cholecystitis, with empyema of the gall bladder. Cultures grew E. coli. The cholangiogram (attached), shows multiple CBD stones. A trans- cystic duct LCBDE was done. The cystic duct was opened close to its confluence with the CBD, as the cystic duct was of larger caliber here. The MIG was used to introduce the choledochoscope into the cystic duct, and a 120 cm x 1.9 Fr. Nitinol stone basket was used to remove these multiple stones. This was a somewhat unusual case in that the choledochoscope could be directed into the hepatic ducts, as well as distally to the ampulla. The ampulla was large enough that the choledochoscope readily would traverse into the duodenum. The PIP feature was useful in speeding up the process of removing such a large number of stones by allowing me switch attention between the two screens, as the stones were captured using the choledochoscope, and then retrieved through the cystic duct and deposited onto the omentum looking at the laparoscopic view. The stones were later retrieved with stone forceps. The cystic duct was closed with an endoloop and a JP drain was left in the sub-hepatic space. One day postoperatively, the amylase was 33. The leukocytosis rapidly resolved, and the patient was discharged on post op day # 3.

I have become more aggressive with the trans-cystic duct LCBDE in the face of larger numbers of stones. The operative time in this case was 187 minutes.