CHAPTER 71: COMMON BILE DUCT EXPLORATION, OPEN

INDICATIONS

Common bile duct exploration should be performed in all patients with common bile duct stones who have either failed, or are not candidates for, endoscopic therapy and who do not have medical conditions that prohibit surgical intervention. Alternative therapies, such as extracorporeal shockwave lithotripsy and dissolving solutions, are not widely available and have limited efficacy. Percutaneous transhepatic cholangiography (PTHC), electrohydraulic lithotripsy, and laser lithotripsy may be useful in a small number of selected patients who are not candidates for surgery or endoscopic therapy. Laparoscopic common bile duct exploration, open common bile duct exploration, and postoperative ERCP with stone removal are all options for the treatment of common bile duct stones identified by intraoperative cholangiography and decision making should be guided by patient-specific considerations, training and experience of the surgeon, and available endoscopic expertise.

Open common bile duct exploration remains an important technique and should be part of every gastrointestinal surgeon’s armamentarium for treating hepatobiliary diseases. Open common bile duct exploration may be performed in patients requiring open cholecystectomy, for patients who have failed or suffered complications from laparoscopic common bile duct exploration, and in circumstances where necessary equipment, experience, and/or resources are limited. Figure 1 depicts schematically the more common locations of calculi.

PREOPERATIVE PREPARATION

In the past, significant time was spent improving hepatic function, as it was believed that anesthesia and surgery were very hazardous in the presence of significant jaundice. Obviously, any coagulopathy must be corrected with vitamin K and blood products, while antibiotics should be given for sepsis or cholangitis. PTHC with retrograde catheter placement for decompression has been largely replaced by endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. This allows stone extraction or stent placement to relieve the obstruction. Appropriate preoperative studies should be obtained (labs, chest x-ray, EKG) as indicated. The patient should be well hydrated and any electrolyte imbalances corrected.

ANESTHESIA

General anesthesia with endotracheal intubation is recommended. Anesthetic agents suspected of hepatotoxicity should be avoided. Blood is promptly replaced as it is lost so as to avoid the development of hypotension.

OPERATIVE PREPARATION

The skin is prepared in the routine manner. Patients are administered appropriate prophylactic antibiotics prior to the time of incision.

INCISION AND EXPOSURE

The abdomen is most commonly opened through a right upper quadrant subcostal incision, although a midline approach is acceptable as well. The use of self-retaining retractors greatly facilitates visualization. The proximal cystic duct should be ligated to prevent gallstones from migrating from the gallbladder into the cystic duct and common bile duct. The liver should be retracted superiorly, the duodenum retracted inferiorly, and the stomach retracted to the left.

DETAILS OF PROCEDURE

Dissection is carried out on the anterolateral common bile duct. The peritoneum overlying the ...