A method for easier laparoscopic cholangiography and common bile duct exploration

Abstract

Both selective and routine cholangiographic approaches have been advocated for the evaluation of intrabiliary stones. Regardless of the approach used, cannulation of the cystic duct for intraoperative cholangiography can be difficult and timeconsuming and can be even moreso for subsequent intraoperative transcystic common bile duct exploration. 1-3 This primarily is from the oblique bend that the cholangiocatheter and other equipment must make to enter and transverse the cystic duct. During the last 20 months a modified technique with entry through the midclavicular seventh intercostal space has been used for both intraoperative cholangiography and transcystic common bile duct exploration. This approach introduces the cholangiocatheter more closely and more parallel to the cystic duct than does a subcostal approach, resulting in an easier and more direct cystic duct cannulation. The improved angle, shorter distance, and lack of oblique bend also permit the placement of a cystic duct introducer catheter (14F peel-away). This introducer catheter allows intraductal manipulations such as stone removal to be performed in relative isolation of the peritoneal cavity and obviates the need to perform repeated intraabdominal cystic duct cannulations with the choledochoscope. An experience using this intercostal approach in more than 300 consecutive laparoscopic cholecystectomies and 13 transcystic common bile duct explorations is presented.