Common bile duct exploration operation Open CBD exploration

Common bile duct exploration operation

Open CBD exploration • Indications • Large stones • If biliary bypass is needed • Trans ampullary approach is difficult or impossible Duodenal diverticulum Long Roux limb post gastrectomy More options than lap CBD exploration

OPEN CBD EXPLORATION BASICS • Fixed retraction • Operator stands on patient’s left side • Generous kocher maneuver ( left hand manipulates CBD over the exploring instrument ) • Use only absorbable sutures • If not completely satisfied, T_tube provides easy future access to the duct and interval decompression

Step by step • Cholecystectomy + IOC • Exposure Packs on hepatic flexure and antrum Fixed retractors on left lobe of liver and hepatic flexure • Instruments, saline and rubber catheter • 4 -0 , 5 -0 sutures

KOCHER MANEUVER

choledochotomy • Localize duct if uncertain 27 g needle • 5 -0 traction sutures • Low (distal ) choledochotomy • Incise CBD with knife • Flush and look before instrumenting

Duct exploration • Latex catheter : 14 -18 Fr for flushing try to gently bypass the ampulla • Palpable stone yes : stone forceps no : choledochoscopy • Adequate if : Confirm duct is clear ( choledochoscopy or T- tube cholangiogram )

choledochoscopy • Be sure to : clear proximal duct see duodenal mucosa

T-tube

• Why ampulla swollen after manipulation access for retained stone • When not needed sphincterotomy or bypass performed very large duct • Leave drain next to T- tube

Post operative • Allow 3 weeks before removing T- tube form tract allow odema to resolve • Always obtain T- tube cholangiogram before pulling tube at least 5% incidence of retained stones