Mastering Cystic Duct Exploration during Laparoscopic Cholecystectomy
إتقان إستكشاف قناة المرارة أثناء إجراء عملية إستئصال المرارة بالمنظار
There is increasing frequency of patients with multiple small stones in the gallbladder, and cystic duct stones are being discovered with increasing frequency during routine laparoscopic cholecystectomy. The traditional milking of cystic duct stones towards the gallbladder during routine laparoscopic cholecystectomy may not be effective especially in cases with wide cystic duct, long cystic duct, multiple small and tiny stones and biliary mud in the gallbladder and cystic duct and cystic duct-CBD junction. These cases are commonly presented with recurrent attacks of acute cholecystitis with elevated alkaline phosphatase and GGT with normal serum bilirubin and preoperative abdominal Ultrasonography usually reveals normal CBD with no CBD stones.
During routine Laparoscopic cholecystectomy, intraoperative cholangiography or choledochoscopy may not be available and even if it is available, cystic duct exploration and clearance should be done at first before embarking on trancystic duct exploration of the CBD if needed.
This unedited video demonstrates step by step technique of cystic duct exploration for a patient with multiple small stones in the gallbladder extending to the cystic duct and cystic duct – CBD junction when intraoperative cholangiography and choledochoscopy are not available.
Preoperative abdominal Ultrasonography for this Patient revealed multiple small and tiny stones with biliary mud in the gallbladder , with normal CBD with no stones in the CBD. Laboratory investigations revealed normal serum bilirubin with elevated alkaline phosphatase and GGT.
Laparoscopic cholecystectomy was done with cystic duct exploration. The cystohepatic mesentery of the triangle of Calot has been well dissected and the critical view of safety has been achieved as seen in the video . A step by step exploration of the cystic duct is shown with extraction of small stones, tiny stones and biliary sludge from the cystic duct and cystic duct CBD junction .
Mastering this technique of cystic duct exploration needs meticulous dissection to achieve the best critical view of safety, gentle cystic duct exploration with laparoscopic skills for extraction of stones and tactile feedback through the laparoscopic instruments, and patience should be exercised during the procedure to achieve the best results, especially if there are no available intraoperative cholangiography or choledochoscopy.The Patient was discharged on the same operative day,
the postoperative period was uneventful and the Patient improved.
Conclusion :
We have found that the technique of cystic duct exploration is very valuable for many of our patients with small gallstones and biliary sludge extending to the cystic duct and cystic duct-CBD junction especially when intraoperative cholangiography and choledochoscopy are unavailable.
We are hoping that this technique would be adopted and popularized among surgeons for treatment of patients with small and tiny stones in the gallbladder to achieve the best results and avoid missing small and tiny stones in the cystic duct and cystic duct-CBD junction after routine laparoscopic cholecystectomy for this increasing group of patients.
This technique can also be done before embarking on intraoperative cholangiography or choledochoscopy for transcystic exploration of the CBD when indicated.
