Common Bile Duct Exploration (CBDE)

David Ray Velez, MD
The Operative Review of Surgery. 2023; 1:41-47.

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Table of Contents

Laparoscopic Common Bile Duct Exploration
Stone Retrieval Techniques
Open Common Bile Duct Exploration
Transduodenal Sphincteroplasty

References

Laparoscopic Common Bile Duct Exploration

Definition

Approaches

  • Transcystic Approach – Through the Cystic Duct
    • Preferred Approach if Able – Protect Integrity of the Common Bile Duct
  • Choledochotomy – Through the Common Bile Duct
    • Indicated if Transcystic Approach Fails or is Contraindicated

Comparison to Preoperative ERCP 1,2

  • Lap-CBDE Has Lower Risk of Technical Failure
  • Lap-CBDE Has Lower Risk of Overall Complications
    • Lap-CBDE Has Lower Risk of Pancreatitis or Perforation
    • Lap-CBDE Has Higher Risk of Bile Leak
  • Lap-CBDE Has Shorter Length of Stay
  • Lap-CBDE Has Fewer Procedures Required

Indications 4

  • Choledocholithiasis Diagnosed Preoperatively by MRCP or US
  • Choledocholithiasis Diagnosed Intraoperatively by Cholangiography
  • Choledocholithiasis After Failed ERCP
  • Choledocholithiasis with Altered Anatomy Unable to Undergo Traditional ERCP (Gastric Bypass, etc.)

Contraindications 4-6

  • Hemodynamic Instability
  • Hostile Porta Hepatis
  • Contraindications to a Transcystic Approach:
    • Friable Cystic Duct
    • Narrow or Tortuous Cystic Duct
    • Large Stones (> 1 cm)
    • Multiple Stones (> 8-10)
    • Common Hepatic Duct Stones
  • Contraindications to a Choledochotomy:
    • Narrow Common Bile Duct (Diameter < 7 mm)

Transcystic Procedure 

  • Generally Attempt Stone Clearance by IOC with Glucagon/Flushing First
  • Dilate the Cystic Duct to 4-6 mm for Instrumentation
    • Maximum 8 mm if Needed
  • Retrieve Stones with Instrumentation Through the Cystic Duct Opening
    • *See Below
  • Confirm Clearance with a Completion Cholangiography
  • Close the Ductal Stump
    • Close Using an Endoloop (Not Clips) to Minimize the Chance of Leak Due to Edema

Choledochotomy Procedure

  • Choledochotomy Incision
    • 0-1.5 cm Longitudinal Incision Below the Cystic Duct Insertion
    • Slightly Medial to Anterior Midline (Avoid Septum of Fused Cystic/CHD)
  • Consider Stay Sutures on Either Side to Keep Open
  • Retrieve Stones with Instrumentation Through the Common Bile Duct – Same Methods as Transcystic Approach
    • *See Below
  • Close Choledochotomy
    • Classically Use an Absorbable Monofilament Suture
    • May Consider Using an Absorbable Knotless Unidirectional Barbed Suture – Facilitates Easier Intracorporal Closure without Increased Complications 8-10
    • May Consider Closing Over a T-Tube Although Falling Out of Favor 11,12

Options If Stone is Impacted and Unable to Remove Laparoscopically

  • Conversion to an Open Common Bile Duct Exploration
  • Leave T-Tube
  • Postoperative ERCP
  • If Preoperative ERCP Failed:
    • Transduodenal Sphincteroplasty
    • Biliary-Enteric Drainage (Side-to-Side Choledochoduodenostomy)

Laparoscopic Stone Removal by Choledochotomy 7

Stone Retrieval Techniques

Fogarty/Balloon Catheter

  • Use a 4-Fr or 5-Fr Fogarty Catheter
  • Balloon Catheter Fed Past the Stone into the Duodenum
  • Balloon Inflated and Slowly Retracted Pulling the Stone Retrograde
  • Stone Pulled Out Through the Ductal Opening

Balloon Sphincteroplasty

  • Use a Balloon Catheter Under Fluoroscopic Guidance to Dilate the Sphincter of Oddi
  • First Gain Guidewire Access into the Duodenum
  • Advance a Balloon Catheter Over the Guidewire into the Duodenum
  • Inflate Balloon in the Duodenum and Retract Under Fluoroscopic Guidance
    • Determine Location of the Sphincter
  • Slightly Deflate, Retract Balloon into the Sphincter, then Reinflate for 3-5 Minutes
    • Larger Balloon Sizes (≥ 10 mm) Prevent Pancreatitis – Limits Postoperative Sphincter Spasm
    • Balloon Should Not Be Larger than the Pathologically Dilated Bile Duct
  • Can Then Facilitate Antegrade Stone Clearance – Done by Flushing, Pushing with a Choledochoscope, or Pushing with a Balloon Catheter Over a Guidewire

Choledochoscope-Guided Wire Basket

  • Choledochoscope Insert Through the Ductal Opening
    • May Use Ureteroscope if Dedicated Choledochoscope is Unavailable
  • Continuous Saline Infusion to Dilate the Lumen & Permit Visualization
  • Wire Basket Passed Beyond the Stone & Opened
  • Ensnare Stone by Retracting Basket with Rotation
  • Stone Pulled Out Through the Ductal Opening

Fluoroscopic-Guided Wire Basket

  • Performed Under Fluoroscopic Guidance
  • Guidewire Passed into the Duodenum Through the Ductal Opening
  • Wire Basket Fed Over the Guidewire
  • Ensnare Stone by Retracting Basket with Rotation
  • Stone Pulled Out Through the Ductal Opening

Novel Approaches

  • Lithotripsy
  • Antegrade Sphincterotomy – Sphincterotome Inserted Through the Cystic Duct to Create a Sphincterotomy

Fogarty Balloon Catheters 13

Large CBD Stone Seen by Choledochoscope 3

Various Wire Baskets 14

Open Common Bile Duct Exploration

Indications

  • Choledocholithiasis During an Open Cholecystectomy
  • Choledocholithiasis After Failure of Laparoscopic Common Bile Duct Exploration
  • Choledocholithiasis if Endoscopy & Laparoscopy are Unavailable

Procedure

  • Ligate Proximal Cystic Duct
  • Choledochotomy Incision
    • 5 cm Longitudinal Incision Just Above Duodenum
  • Use Stay-Sutures on Either Side to Keep the Choledochotomy Open
  • May Require Kocher Maneuver to Mobilize the Duodenum
  • Retrieve Stones
    • *See Below
  • Consider T-Tube if Suspect Residual Stones or Concern for Stricture
  • Close with Absorbable Monofilament Suture

Methods to Retrieve Stones

  • Manual Expression
    • Generally Preferred as the Initial Method
  • Forceps Removal
    • Classically Using Desjardins Gallstone Forceps
  • Fogarty/Balloon Catheter
  • Choledochoscope-Guided Wire Basket

Closure Options

  • Primary Closure
    • Use an Absorbable Monofilament Suture
    • Historically Concerned for Risk of Biliary Stricture but Recently Being Disproven 11
  • Closure Over a T-Tube
    • Historically the Gold Standard Closure but Now Falling Out of Favor
    • Increased Risk of Complications, Leaks, Longer Operating Time, and Longer Hospital Length of Stay 11,17
  • Less Common Options:
    • C-Tube (Through the Cystic Duct Stump)
    • Antegrade Stenting

Postoperative Management of a T-Tube

  • Repeat Cholangiogram at 24-48 Hours
    • If Normal: Keep Clamped & Flush with Saline Once-Twice Per Day
    • If Obstructed/Retained Stone: Leave Open to Drain
  • Repeat Cholangiogram at 10-14 Days
    • If Normal: Remove
    • If Obstructed/Retained Stone: ERCP or IR Intervention per T-Tube

Options If Stone is Impacted and Unable to Remove

  • Leave T-Tube
  • Postoperative ERCP
  • If Preoperative ERCP Failed:
    • Transduodenal Sphincteroplasty
    • Biliary-Enteric Drainage (Side-to-Side Choledochoduodenostomy)

Open Choledochotomy with Retention Sutures 15

Desjardins Gallstone Forceps

Biliary T-Tube 16

Transduodenal Sphincteroplasty

Definition

  • Sphincteroplasty Performed in an Open Fashion Made through an Incision in the Duodenum
  • *Fallen into Disuse with Modern Endoscopic Interventions

Indications

  • Impacted Stone After Common Bile Duct Exploration (Generally Only if Postoperative ERCP is Otherwise Contraindicated – i.e. Failed Preoperatively)
  • Sphincterotomy Otherwise Indicated but Endoscopic Approach is Contraindicated:
    • Recurrent Stricture After Endoscopic Sphincterotomy
    • Ampulla Endoscopically Inaccessible
    • Pancreatic Divisum

Procedure

  • Kocher Maneuver to Mobilize the Duodenum
  • Longitudinal Duodenotomy On the Lateral Side
  • Insert a Soft Catheter, Probe, or Right-Angle into the Common Bile Duct Through the Ampulla of Vater
  • Use a Pott’s Scissors or Scalpel to Cut the Papilla at the 11 O’clock Position
    • Cut 15 mm in Length
  • Clear the Common Bile Duct Stone
  • Suture the Bile Duct Wall to the Duodenal Mucosa
    • Start with the Apical Suture and Continue Along the Sides in Interrupted Fashion
    • Use a 4-0 or 5-0 Absorbable Monofilament Suture
  • Close the Duodenotomy Transversely

Transduodenal Sphincteroplasty 18

References

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  18. Velez DR. Transduodenal Sphincteroplasty. The Operative Review of Surgery.