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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 (PTC), 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 endoscopic retrograde cholangiopancreatography (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, the 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, in 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

The metabolic derangements associated with hyperbilirubinemia in the setting of choledocholithiasis pose significant challenges that should be addressed prior to surgical intervention. Coagulopathy must be corrected with vitamin K and blood products, and antibiotics should be given for sepsis or cholangitis. Appropriate preoperative studies should be obtained (e.g., laboratory studies, chest x-ray, and electrocardiogram) as indicated. Patients should be well hydrated and any electrolyte imbalances corrected. Nonoperative interventions, when equipment and expertise are available, should be considered. PTC with antegrade catheter placement for decompression has been largely replaced by ERCP, which allows endoscopic stone extraction, sphincterotomy, and/or stent placement to relieve the obstruction.

ANESTHESIA

General anesthesia with endotracheal intubation is recommended. Anesthetic agents suspected of hepatotoxicity should be avoided.

OPERATIVE PREPARATION

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

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 THE PROCEDURE

The gallbladder, if present, should be removed as described in Chapter 74. Dissection is carried out on ...

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