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The decision to explore the common duct depends not only on the patient's preoperative history and laboratory examination but also on the anatomic findings by palpation and inspection at the time of open operation. The presence of jaundice or a recent history of jaundice is a strong indication for exploration of the common duct. The common duct is explored if there is, on palpation, a suspicion of a stone; if the common duct is thickened or dilated; if the cystic duct is sufficiently dilated to permit stones to pass into the common duct; if the head of the pancreas is thickened, suggesting a chronic pancreatitis; or if there are one or more very small stones in the gall-bladder or cystic duct, which, because of their size, could easily pass into the common duct. More than 15 percent of patients with cholelithiasis present indications for exploration of the common duct unless a routine cholangiogram through the cystic duct is clearly negative. In approximately one-third of the common ducts explored, one or more stones will be recovered. Figure 1 depicts schematically the more common locations of calculi.
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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. Percutaneous transhepatic cholangiography (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. Additionally, tumors may be visualized, biopsied, or studied with endoluminal ultrasound. Accordingly, the principal indication for open exploration of the common duct is the inability to clear the common duct stones and obstruction by ERCP. This may occur as a primary procedure or, more likely, after a laparoscopic cholecystectomy that failed to clear the stones with advanced laparoscopic techniques. The patient should be well ...