Overview
Definition:
Common bile duct exploration (CBDE), also known as choledochotomy, is a surgical procedure performed to directly visualize, diagnose, and treat abnormalities within the common bile duct (CBD)
This typically involves opening the CBD to remove stones, retrieve retained fragments, or biopsy suspicious lesions
It can be performed open or laparoscopically.
Epidemiology:
Gallstones are the most common cause of CBD stones, affecting approximately 10-20% of patients with symptomatic cholelithiasis
Choledochotomy is indicated in a subset of these patients requiring definitive stone removal or management of other CBD pathology
The incidence of CBD stones increases with age.
Clinical Significance:
Failure to adequately clear the CBD of stones or other pathology can lead to serious complications such as ascending cholangitis, pancreatitis, and liver abscesses
CBDE is crucial for preventing these adverse outcomes, restoring biliary drainage, and alleviating symptoms like jaundice and pain
It is a critical skill for surgical residents preparing for examinations and for providing optimal patient care.
Indications
Absolute Indications:
Preoperative diagnosis of CBD stones on imaging (ERCP, MRCP, CT, Ultrasound)
Presence of CBD stones confirmed intraoperatively during laparoscopic cholecystectomy
Cholangitis with suspected CBD stones
Obstructive jaundice with elevated liver function tests and suspected CBD pathology.
Relative Indications:
Acute pancreatitis of biliary origin with suspected CBD stones
Intraoperative bile duct injury requiring exploration
Suspected retained common bile duct stones after previous ERCP
Biliary strictures with suspected malignancy or impacted stones.
Contraindications:
Unstable patient requiring immediate resuscitation without time for surgical intervention
Severe coagulopathy not correctable
Ascites or significant comorbidities precluding surgical risk
Unfit for general anesthesia.
Preoperative Preparation
History And Physical Examination:
Thorough history including symptoms of pain, jaundice, fever, and prior biliary interventions
Physical exam focusing on signs of jaundice, hepatomegaly, and right upper quadrant tenderness.
Laboratory Investigations:
Complete blood count (CBC) for leukocytosis
Liver function tests (LFTs) including bilirubin, alkaline phosphatase, AST, ALT, GGT
Coagulation profile (PT/INR, aPTT)
Serum amylase/lipase to assess for pancreatitis
Blood cultures if cholangitis is suspected.
Imaging Modalities:
Ultrasound of the abdomen to visualize gallstones and CBD diameter
Magnetic Resonance Cholangiopancreatography (MRCP) for detailed biliary tree anatomy and stone detection
Endoscopic Retrograde Cholangiopancreatography (ERCP) for diagnosis and therapeutic intervention (stone extraction, stenting)
Computed Tomography (CT) scan for alternative diagnoses or complications.
Antibiotic Prophylaxis:
Administer broad-spectrum intravenous antibiotics (e.g., third-generation cephalosporin with metronidazole or a fluoroquinolone) at least 30-60 minutes prior to incision, especially in patients with suspected cholangitis
Continue postoperatively based on clinical suspicion and intraoperative findings.
Informed Consent:
Discuss the procedure, risks (bleeding, infection, bile leak, retained stones, injury to surrounding structures, pancreatitis, death), benefits, and alternatives with the patient and obtain written informed consent.
Procedure Steps
Approach Selection:
Laparoscopic approach is preferred for most cases due to minimally invasive nature, faster recovery, and reduced pain
Open approach is reserved for cases with severe adhesions, extensive CBD pathology, or inability to perform laparoscopically.
Laparoscopic Choledochotomy:
Laparoscopic cholecystectomy is performed first
The CBD is then identified and dissected
A longitudinal incision is made in the CBD, typically near the superior aspect
Stones are removed using gentle irrigation, stone baskets, or Fogarty catheters
The duct is then flushed to confirm complete clearance
Cholangiography may be performed to assess residual stones or bile leaks
Closure or drainage: The CBD may be left open with a T-tube if there is significant edema or residual debris, or closed over a drain
Transcystic or direct choledochotomy can be employed.
Open Choledochotomy:
A subcostal or midline laparotomy is performed
The CBD is identified and dissected
Incision and stone removal are performed similarly to the laparoscopic approach
A T-tube is typically placed for drainage and postoperative cholangiography
The abdominal incision is then closed.
Intraoperative Cholangiography:
Performed to confirm the presence of stones, their location, and to assess for residual fragments and bile leaks after clearance
Crucial for guiding the extent of exploration and operative decision-making.
Completion Of Procedure:
If a T-tube is placed, it is secured and brought out through a separate stab incision
The gallbladder is removed (if not already done)
The abdomen is irrigated, and drains are placed as necessary before closure.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and abdominal distension
Monitor for signs of bleeding, infection (fever, leukocytosis), bile leak (bilious drainage from drains, abdominal pain), or pancreatitis.
Pain Management:
Adequate analgesia is crucial, often requiring patient-controlled analgesia (PCA) or epidural analgesia
Opioid and non-opioid analgesics are used.
Fluid And Electrolyte Balance:
Intravenous fluid resuscitation as needed
Monitor electrolyte levels and correct abnormalities
Maintain adequate hydration.
Antibiotics:
Continue intravenous antibiotics as dictated by intraoperative findings and clinical suspicion of infection
Transition to oral antibiotics when appropriate.
Drain Care:
If drains are placed, monitor the output and character of the fluid
Remove drains when output is minimal and non-bilious.
T-tube Care And Cholangiography:
If a T-tube is in place, ensure it is patent and draining bile
Postoperative cholangiography is usually performed on postoperative day 5-7 to confirm complete stone clearance and assess for leaks
The T-tube is typically removed after a normal cholangiogram if there are no retained stones or leaks.
Complications
Early Complications:
Bile leak from the ductotomy site or T-tube insertion site
Retained CBD stones
Hemorrhage from the CBD
Cholangitis
Pancreatitis
Injury to surrounding structures (e.g., hepatic artery, portal vein)
Wound infection.
Late Complications:
Bile duct stricture formation at the site of exploration or T-tube removal
Cholangitis due to retained stones or strictures
Biliary-enteric fistula
T-tube dislodgement or blockage.
Prevention Strategies:
Meticulous surgical technique, adequate visualization of the CBD, thorough flushing, intraoperative cholangiography, judicious use of T-tubes, early identification and management of bile leaks, careful T-tube removal after confirming patency of the biliary tree.
Key Points
Exam Focus:
Indications for choledochotomy, laparoscopic vs
open approach, steps of laparoscopic CBD exploration, management of retained stones, complications of CBDE, T-tube management and cholangiography timing.
Clinical Pearls:
Always suspect CBD stones in patients with jaundice and elevated alkaline phosphatase
Intraoperative cholangiography is invaluable for assessing the CBD
Gentle manipulation is key to avoid ductal injury
If intraoperative cholangiography is difficult, consider postoperative ERCP or MRCP.
Common Mistakes:
Inadequate exploration of the CBD, failure to confirm complete stone clearance, aggressive manipulation causing ductal injury, premature removal of T-tube before confirming patency, delayed diagnosis and management of bile leaks.