OGBN O09V Multi-modal Approach with Fluorescence Imaging, Intraoperative Ultrasound and Laser Lithotripsy in the Laparoscopic Management of Complex Large Bile Duct Stones

Abstract

Abstract Background Choledocholithiasis is a common condition with various presentations. There are several approaches through which this can be managed. This presentation aims to explain novel techniques and various modalities in managing complex bile duct stones successfully with minimal invasive approach. Methods This video presentation depicts the procedure performed for large CBD stones with the use of indocyanine green (ICG) and intraoperative ultrasound (IOUS). The patient is a 61 year old gentleman presented with abdominal discomfort and deranged liver functions. Cross sectional imaging showed 2 large CBD calculi and attempt at endoscopic retrograde cholangio-pancreatigoraphy (ERCP) failed due to large impacted stones. Decision was made to proceed to single stage laparoscopic cholecystectomy and common bile duct exploration with use of ICG, IOUS and laser lithotripsy to achieve successful clearance of CBD. Results At laparoscopy, the CBD and common hepatic artery were identified with ICG and IOUS. A vertical choledochotomy was performed and choledochoscopy undertaken. Attempts to retrieve the stone with extraction basket were not successful. Laser lithotripsy was used to break the stones into smaller fragments which were subsequently retrieved using atraumatic graspers and extraction wire. Post operative period was uneventful and the patient was discharged home on day 2. Face to face follow-up at 6 weeks confirmed good recovery. Conclusions Laparoscopic management of complex CBD stones is challenging. Despite advances in endoscopy intervention, the role of surgery is irrefutable. Advanced laparoscopic skills and experience in bile duct exploration with advanced minimally invasive instruments and equipment are critical to achieve optimal patient outcomes, and mitigated the chances of conversion to open surgery which its associated morbidity. This presentation demonstrates a safe technique while working in the hostile area of the inflamed hepatocystic triangle and an alternative method in the retrieval of large common bile duct stones following failed ERCP.