Using the MIG

The following is the suggested procedure for performing Laparoscopic Common Bile Duct Exploration (LCBDE) using LapSurgical's Multiple Instrument Guide. Click Here for a printable version of this manual. Click Here for the simplified procedural algorithm for performing MIG enhanced LCBDE.

Equipment Requirements for LCBDE Using the MIG

• Laparoscopic video system with dual cameras and picture in picture capability
• Laparoscopic port set for laparoscopic cholecystectomy
• Complete set of advanced laparoscopic instrumentation
• 2.8 or 3.2mm flexible choledochoscope
• MIG (Multi-channel Instrument Guide
• 4Fr. or 5Fr. balloon and irrigation catheters
• 1.7Fr. OD electrohydraulic lithotripter probe Or 200 micron laser fiber for Holium laser
• 1.9 Fr Nitinol Stone Basket
• Sureseal Endoscopic Valve
• Pressure irrigation tubing to attach to working channel choledochoscope and to irrigation catheter
• T-tube Whelan-Moss 12/18

CPT Codes for LC and LCBDE

Suggested Procedure

For a short video clip of each sequence, click on the accompanying picture. The video files are in MPG format and should be compatible with most media players such as Quicktime or Windows Media Player.

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	1. Perform operative cholangiogram.
	2. Identify the common bile duct.
	3. Perform anterior longitudinal (7-12mm) choledochotomy.
	4. Pull MIG into introducer sheath to facilitate entry of the instrument into laparoscopic port. Wet the MIG inside and out with sterile saline to activate hydrophilic lubricious coating (for friction reduction).
	5. Insert 2.8mm choledochoscope into 3.4mm MIG channel. Note: curvature of choledochoscope tip should parallel the curvature of the MIG's tip.
	6. Insert 4Fr. balloon catheter and 4Fr. or 5Fr. irrigation catheter into the two smaller MIG channels, otherwise insert the occlusion plug into one or both of the smaller MIG channels.
	7. Insert the introducer sheath and MIG with associated choledochoscope and catheters through a 10mm laparoscopic port positioned above the choledochotomy. 8. Advance the MIG through the introducer sheath and it will reassume the curved tip configuration.
	9. Advance the MIG tip into the choledochotomy. 10. Start irrigation through irrigation catheter to distend the CBD.
	11. Advance the video choledochoscope into the CBD to identify anatomy and pathology.
	12. Use video choledochoscope to guide application of balloon catheter, irrigation catheter, stone basket, biopsy forceps, and/or electrohydraulic lithotripter to dislodge and/or destroy CBD stones for removal. Use of instruments and combinations of instruments is at the discretion of the laparoscopic surgeon based on the particulars of each case.
	Note: The lithotripter is best deployed through the working channel of the choledochoscope with an irrigation catheter deployed in adjacent MIG lumen. Caution: Lithotripter must be in direct contact with stone. Contact with the wall of the bile duct may lead to perforation or injury.
	13. Choledochoscope and catheters may be withdrawn into the MIG, and the MIG rotated 180 degrees to inspect proximal hepatic ducts.
Note: Choledochoscope and catheters are withdrawn into the MIG and the MIG is withdrawn into the sheath during removal (or insertion) of apparatus.
	14. After completion of LCBDE, a T-tube is placed along with a closed suction drain, particularly when cholangitis, distal bile duct obstruction, or edema is present.