Laparoscopic Common Bile Duct Exploration For Stone Associated With Surgical Foreign Body

Abstract

Presenter: Morgan Bonds MD | Virginia Mason Medical Center Background: Choledocholithiasis is a common problem that presents to hepatopancreatobiliary surgeons. As more patients undergo procedures that alter the anatomy of the proximal gastrointestinal tract, common bile duct exploration emerges as one of the few options to treat these patients. Laparoscopic common bile duct exploration has been shown to shorten hospital length of stay in these situations. In this video we present a patient who has undergone a cholecystectomy and roux-en-y gastric bypass and presented with choledocholithiasis that appeared to be associated with a surgical clip. Methods: Our patient is a 61 year old woman who presented with acute onset epigastric pain. On computed tomography, a stone was visualized within the distal common bile duct. This stone appeared to be surrounding a hyperdense foreign body consistent with a surgical clip. She had previously undergone a cholecystectomy and roux-en-y gastric bypass that was complicated by an ulcer perforation requiring resection of the gastric remnant. Double balloon endoscopy was attempted to access the common bile duct but was not successful. Surgery was consulted for laparoscopic common bile duct exploration. Results: The video presents the key steps for performing laparoscopic common bile duct exploration which includes choledochotomy, performing choledochoscopy to locate the pathology, stone extraction and closure of the choledochotomy. We were able to identify the offending stone on choledochoscopy and it was removed. No foreign body or mucosal erosion was seen within the duct. The choledochoscopy was closed primarily without a drain as an internal drain would not be retrievable with her altered anatomy. She had a bile leak controlled by her peritoneal drain in the immediate postoperative period but this resolved within the first week and her drain was removed on postoperative day 7. Conclusion: Laparoscopic common bile duct exploration is a safe and effective method of treating choledocholithiasis in patients with altered anatomy in the setting of a suspected foreign body within the duct. Closure of the choledochotomy should be individualized to the patient and clinical scenario. This technique should be considered to shorten the length of stay for all patients with choledocholithiasis.