EGS P32V Laparoscopic transcystic Antegrade Biliary Stenting

Abstract

Abstract Background Laparoscopic cholecystectomy is the gold standard treatment for symptomatic cholelithiasis including pancreatitis. Symptomatic gall stones patients have up to 20% risk of having common bile duct (CBD) stones too. Although, guidelines have been laid down for management of suspected CBD stones, in practice there is a lot of variability and lack of standardisation. The waiting list for Magnetic resonance cholangiopancreatography (MRCP) is long, resulting in delayed treatment and increased length of hospital stay. Similarly, pre-operative endoscopic retrograde cholangiopancreatography (ERCP) can also increase the length of hospital stay due to long waiting lists, limited availability and overall risk of complications as high as 30%. Hence, the role of on-table cholangiogram (OTC) while performing laparoscopic cholecystectomy has been explored. The guidelines state that OTC should be performed in fit for surgery patients, without pre-operative investigations for diagnosing CBD stones. We have been practising early cholecystectomy with on-table cholangiogram (during the index admission), with selective insertion of antegrade biliary stent in patients with choledocholithiasis. We facilitate ERCP with stent removal and clearance of CBD stones after 4 weeks post-operatively. We aim to present our technique of laparoscopic antegrade biliary stent insertion. Methods We follow the standard four-port technique for Laparoscopic cholecystectomy. Following dissection of Calot's triangle and visualisation of ‘critical view of safety’, an on-table cholangiogram is performed using a standard technique. If CBD stones are visualised, a transcystic antegrade stenting is done by Seldinger technique (without clearing the CBD of stones). The cholangiogram catheter is removed and flex-tip ureteric catheter is inserted transcystically. Through the ureteric catheter a flex-tip guidewire is inserted into CBD till its tip is visualised in the duodenum, under C-arm guidance. The ureteral catheter is then withdrawn carefully with guidewire placed satisfactorily. A double pig tail end biliary stent is rail-roaded over the guidewire, using a pushing catheter fashioned appropriately. As soon as the tip of the stent is visualised beyond the ampulla (in the X-ray), the guidewire and pushing catheter are withdrawn. The curling up of both ends of the stent is visualised and confirmed through C-arm guidance. Thereafter the procedure of cholecystectomy, as standard, is completed. Results The results of this procedure were analysed from 2014 to 2017, and subsequently published in 2018. Conclusions This technique does not involve skills required for CBD exploration. Hence, can be performed by general surgeons with expertise in minimal access surgeries, as it does not involve a steep learning curve. This technique is safe, reliable and cost-effective. It also decreases delays in biliary decompression, in-hospital stay and ensures timely treatment.