Abstract

Step 1—preparation of the CD

The procedure begins with dissection and isolation of the CD and cystic artery. ICG-FC may be used to improve visualization of the CD. The cystic artery is closed with 10 mm titanium clips. In this case the CD is dilated preventing its complete closure with clips and the infundibulum is closed with a ligature.

Step 2—attempted trans-cystic CBD exploration

The CD is opened with scissors. IOC is omitted because preoperative cholangio-magnetic resonance imaging (MRI) demonstrated the presence of one ductal stone.

Step 3—laparoscopic choledochotomy and stone extraction

A short transverse choledochotomy is performed and direct exploration of the CBD and CHD is carried out with the flexible choledochoscope. The scope is inserted through the CBD opening, directing its tip towards the papilla. After the stone is visualized, a four wire, flat stone extractor catheter is advanced through the working channel of the choledochoscope and the basket is deployed after passing its tip beyond the stone. The catheter is then withdrawn from the CBD until the stone is entrapped. The catheter is then pulled back to the tip of the scope which is retrieved to the peritoneal cavity where the stone is released and retrieved. Next, the choledochoscope is directed towards the intrahepatic ducts to check for the absence of residual stones.

Step 4—choledochotomy closure

The choledochotomy is closed with a continuous 4.0 absorbable suture. The cystic artery is divided between clips. The thickened CD is closed with a suture and it is then divided.

Step 5—cholecystectomy and gallbladder extraction

After closure of the CD, retrograde cholecystectomy is performed, and the gallbladder is removed with a specimen retrieval bag.

Keywords: Laparoscopic CBD