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General Surgery
Laparoscopic Biliary Procedures
Built from Maingot's Abdominal Operations
What’s inside
8 sections · 119 slides
Overview
- Scope of laparoscopic biliary surgery
- Terms and abbreviations used in this topic
- Plan of this topic
Evaluating the common bile duct
How stones in the main duct are looked for during a cholecystectomy
- Frequency and natural history of common bile duct stones
- Complications of a retained duct stone
- Standard ways of evaluating the duct
- 90%
- Arguments for routine intraoperative cholangiography
- Arguments against routine intraoperative cholangiography
- Evidence on bile duct injury with routine versus selective use
- Cost of finding one unsuspected duct stone
- Recommended policy on cholangiogram use
- Indications for a laparoscopic cholangiogram
- Preoperative factors that indicate a cholangiogram
- Intraoperative factors that indicate a cholangiogram
- Steps in taking a laparoscopic cholangiogram
- Preparing the cystic duct for the catheter
- Cholangiogram catheter secured in the cystic duct
- Preparing contrast and clearing air bubbles
- Patient position and imaging equipment
- Findings a complete cholangiogram must document
- Laparoscopic ultrasound of the bile duct
- Advantages and drawbacks of laparoscopic ultrasound
Managing stones in the common bile duct
Choosing between ERCP, laparoscopic clearance, and open surgery
- Choledocholithiasis and the site of obstruction
- Factors that decide how duct stones are managed
- Algorithm for stones diagnosed before the operation
- Reading the preoperative algorithm
- Algorithm for stones found during the operation
- Presentation of stones diagnosed before operation
- Worked examples from the preoperative algorithm
- 90-95%
- Qualifications to the reported success rates
- Role of sphincterotomy at ERCP
- Factors guiding the choice of clearance method
- Indications for preoperative ERCP in choledocholithiasis
- Indications for preoperative ERCP
- Stones found unexpectedly during the operation
- Managing small stones found on cholangiogram
Clearing the duct through the cystic duct
Flushing, balloons, baskets, and the choledochoscope
- Escalating options for clearing the duct
- Flushing the duct with saline and glucagon
- Stone flushed through the ampulla
- Balloon catheter retrieval of duct stones
- Steps of the balloon sweep
- Balloon dilation of the ampulla and sphincter of Oddi
- Technique of ampullary balloon dilation
- Safety limits and results of ampullary dilation
- <10%
- Basket retrieval of duct stones
- Basket use with fluoroscopy
- Basket use without fluoroscopy
- Risk of capturing the papilla with a basket
- Transcystic exploration with a choledochoscope
- Safe limits of cystic duct dilation
- Methods of cystic duct dilation
- Flexible choledochoscope passed into the duct
- Negotiating the scope through the cystic duct
- Removing stones under direct vision
- Completing a transcystic exploration
Choledochotomy and T-tube drainage
Opening the duct directly when the transcystic route will not work
- Indications for a transductal exploration
- Advantages and patient selection for laparoscopic choledochotomy
- Making the choledochotomy
- Exploring the duct through the choledochotomy
- Choosing and preparing the T-tube
- Bringing the T-tube out of the abdomen
- Closing the duct over the T-tube
- Intracorporeal knot tying at the choledochotomy
- Finishing the choledochotomy operation
Biliary bypass and reconstruction
Rerouting bile when the duct is obstructed or must be replaced
- Current place of laparoscopic biliary resection and reconstruction
- Endoscopic stenting for malignant obstruction
- Patients better served by surgical bypass
- Bypass for benign biliary disease
- Principles that do not change with laparoscopy
- Laparoscopic cholecystojejunostomy as palliation
- Cholangiography before cholecystojejunostomy
- Contraindications to laparoscopic cholecystojejunostomy
- Absolute contraindications to cholecystojejunostomy
- Relative contraindications to cholecystojejunostomy
- Proportion of patients eligible for cholecystojejunostomy
- Port placement for laparoscopic cholecystojejunostomy
- Steps of stapled cholecystojejunostomy
- Confirming cystic duct patency at operation
- Selecting and positioning the jejunal loop
- Stay suture to align bowel and gallbladder
- Creating the enterotomy and cholecystotomy
- Firing the stapled anastomosis
- Inspecting the anastomosis
- Bringing up the loop and inserting the stapler
- Opening the bowel and inspecting the completed join
- Closing the remaining defect by transverse stapling
- Closing the defect and finishing
- Alternatives to the stapled anastomosis
- Drawback of cholecystoenteric bypass
- Choledochoduodenostomy and hepaticojejunostomy
- Benign indications for these bypasses
- 300 min
- Reported laparoscopic hepaticojejunostomy experience
- Instruments that shorten intracorporeal suturing
- Technical modification for laparoscopic choledochoduodenostomy
Choledochal cysts
A congenital dilatation of the bile ducts, and its laparoscopic excision
- Choledochal cyst as a congenital biliary dilatation
- Presentation and timing of diagnosis
- Malignant risk and the case for treating every cyst
- Classification and surgical treatment of choledochal cysts
- Types of choledochal cyst and their operations
- Treatment of the type I choledochal cyst
- Rationale for a minimally invasive approach in children
- Published experience with laparoscopic cyst excision
- Steps of laparoscopic choledochal cyst excision
- Advantages and disadvantages of the laparoscopic approach to cysts
Where this leaves practice
Conclusions the authors draw
- Current state of laparoscopic duct clearance
- Place of laparoscopic duct treatment in practice
- Requirements for laparoscopic biliary reconstruction
- Points to carry away
- References
- References (continued)
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- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition