Novel Technique for Laparoscopic Common Bile Duct Exploration Using Endovascular Instrumentation

Abstract

Treatment of choledocholithiasis is sometimes a two-step process involving both surgeons and gastroenterologists. Common bile duct (CBD) exploration can be performed at the same time as cholecystectomy but often requires the use of rigid tools, increasing the risk of CBD damage. Here, we report the case of a 64-year-old man who presented with epigastric pain and a positive Murphy's sign. Ultrasonography revealed cholecystitis with cholelithiasis. Gangrenous cholecystitis was visualized upon surgical exploration, and an intraoperative cholangiogram diagnosed likely choledocholithiasis. Cholecystectomy was completed, and CBD exploration was performed by the manipulation of endovascular equipment using a trans-cystic approach through to the ampulla of Vater, and the patient made a complete recovery without complications. The substantial flexibility, gentleness, and durability of endovascular instruments allow for minimal tension on structures during the removal of gallstones from the CBD, providing safe, definitive treatment for choledocholithiasis during cholecystectomy.

Keywords: acute cholecystitis; choledocholithiasis; endovascular surgery; laparoscopic cholecystectomy; laparoscopic surgery; laparoscopy; minimally invasive surgery; surgical technique.

Figure 1. Intraoperative cholangiogram prior to common bile duct exploration demonstrating obstruction of flow near the ampulla of Vater (black arrow). This is suggestive of choledocholithiasis.

Figure 2. Intraoperative cholangiogram following glucagon administration. In comparison to the previous cholangiogram, this one demonstrates little improvement in flow past the ampulla of Vater (black arrow), suggesting persistence of choledocholithiasis.

Figure 3. Radiographic imaging demonstrating a glidewire and TEMPO AQUA® catheter passed through the common bile duct and ampulla of Vater (black arrows).

TEMPO AQUA® (Cordis, Milpitas, California, US)

Figure 4. Intraoperative cholangiogram depicting moderate relief of common bile duct obstruction and flow of contrast into the duodenum following balloon dilation of the ampulla of Vater. However, the ampulla is still opacified (black arrow), suggesting possible persistence of a gallstone.

Figure 5. Repeat cholangiogram following a second dilation indicative of therapeutic success as there is free flow of contrast through the biliary system and through the ampulla of Vater (black arrow).