Page 8 - WJOLS - Laparoscopic Journal

TK Neelamekam, Premkumar Balachandran

Management treatment for ductal calculi. They cause symptoms within
two years of the initial surgery or treatment.
The plan was to stabilize the patient, decrease S. Bilirubin
preoperatively and take up the patient for surgery. The patient
was hydrated with intravenous fluids, antibiotics and proton Recurrent
pump inhibitors were given. One gram of Inj. Vitamin K These are primary ductal calculi composed of soft brown
was given intramuscularly for three days. pigment that form two years after common duct exploration
The patient was then subjected to ERCP. The findings or other treatment.
of which were: There are various therapeutic options available for the
• Dilated CBD, short parallel cystic duct, multiple calculi. management of common bile duct stones:
Sphincterotomy was done and one calculus extracted • Open surgery
from the CBD. A pigtail stent was placed. Pus was seen • Laparoscopy
while cannulating the cystic duct. • Endoscopy
After 48 hours the patient was taken up for surgery. A • Lithotripsy
laparoscopic common bile duct exploration, extraction of • Chemical dissolution.
all stones, T-tube drainage and cholecystectomy was done.
The postoperative period was uneventful and the patient Role of Open Surgery
was discharged on the seventh postoperative day. She was
reviewed after three weeks when a T-tube cholangiogram • Patients unfit for laparoscopic surgery
was done and the T-tube was removed after ensuring that • All surgeons attempting laparoscopic biliary surgery
no stones were present in the duct. should have experience of open biliary surgery
• In the event of any mishap or in the presence of
DISCUSSION significant technical difficulty the laparoscopic surgeon

Introduction should be able to convert to open surgery and complete
the operation.
Ductal calculi have a varied clinical presentation and
management. Therapeutic options differ from open surgery Laparoscopic Removal of Ductal Stones
to endoscopic and laparoscopic methods. Laparoscopic Bile duct exploration can be done through the cystic duct
biliary surgery has advanced significantly over the last and the common bile duct. Laparoscopy can also be
decade. Its introduction has made it possible to overcome
some of the drawbacks of other therapeutic approaches. combined with other methods like endoscopy and lithotripsy.
This article analyses the current management of ductal However, not all patients can undergo a transcystic
calculi. exploration and will require a supraduodenal choledocho-
tomy. The indications for choledochotomy are:
Ductal Calculi • Presence of large (>1 cm) calculi
• Several (> 5 stones)
Primary • Stones in the common hepatic duct

Primary calculi form within the bile ducts. They should be • Very low and spiral cystic duct–common hepatic duct
suspected if a patient develops stones two years or longer, junction.
after cholecystectomy, or if their composition differs from Once the bile duct has been explored, a T- tube drainage,
that of gallbladder calculi. These are made of soft brown a biliary enteric anastomosis or a direct closure of the bile
pigment and harbour bacteria within surface pits thereby duct can be performed. The indications for T-tube drainage
have a strong association with biliary infection and stasis. are:
• To prevent bile leakage from the dochotomy at the lower
Secondary
end of the CBD.
Secondary calculi form in the gallbladder and then migrate • Large CBD (> 2 cm) and multiple primary brown
to the ductal system. In this case the composition is identical stones.
to gallbladder calculi. The T-tube is also useful for removal of retained stones
by flushing or by the Burhenne’s technique using baskets
Retained for retrieval. The tube is kept in situ for two weeks and
These are calculi that are undetected (missed), or detected following this a T- tube cholangiogram is done. If the biliary
but intentionally not removed during surgery, or other tree is normal the tube is removed. If stones are detected

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