Diagnosis

& Management
Internal Clinical Guidelines Team (UK). Gallstone Disease: Diagnosis and
Management of Cholelithiasis, Cholecystitis and Choledocholithiasis. London:
National Institute for Health and Care Excellence (UK); 2014 Oct. (NICE
Clinical Guidelines, No. 188.) Available from:
https://www.ncbi.nlm.nih.gov/books/NBK258747/
Internal Clinical Guidelines Team (UK).
Gallstone Disease: Diagnosis and Management of
Cholelithiasis, Cholecystitis and
Choledocholithiasis. London: National
Institute for Health and Care Excellence (UK);
2014 Oct. (NICE Clinical Guidelines, No.
188.) Available from:
https://www.ncbi.nlm.nih.gov/books/NBK258747/
Internal Clinical Guidelines Team (UK). Gallstone Disease: Diagnosis and Management of Cholelithiasis, Cholecystitis and Choledocholithiasis.
London: National Institute for Health and Care Excellence (UK); 2014 Oct. (NICE Clinical Guidelines, No. 188.) Available from:
https://www.ncbi.nlm.nih.gov/books/NBK258747/
Narula, V. K., Fung, E. C., Overby, D. W., Richardson, W., &
Stefanidis, D. (2020). Clinical spotlight review for the
management of choledocholithiasis. Surgical Endoscopy, 34(4),
1482-1491. doi:10.1007/s00464-020-07462-2
Diagnosis
Blood Tests
• ↑ WBC count → cholecystitis
• ↑ bilirubin, ALP, and AST/ALT → cholangitis should be suspected
• Serum aminotransferases may be normal or mildly elevated
• Blood tests will typically be normal in biliary colic or chronic cholecystitis
Diagnosis
Ultrasonography
• Stones/polyp produce an acoustic shadow
• Thickened gallbladder wall and local tenderness indicate cholecystitis
• Dilation of the ducts in a patient with jaundice establishes an extrahepatic
obstruction as a cause for the jaundice
Management
Laparoscopic Cholecystectomy with
Intraoperative Cholangiogram, possible
Common Bile Duct Exploration
Laparoscopic Cholecystectomy
TECHNIQUE
• The patient is placed supine with the arms
either secured at the sides or out at right
angles.

INCISION AND EXPOSURE

• The abdomen is palpated to find the liver edge
or unsuspected intra-abdominal masses.
• The patient is placed in a mild trendelenburg
position and an appropriate site or the creation
of the pneumoperitoneum is chosen.
• The initial port may be placed by an open, or
Hasson, technique and this is generally
preferred.
Laparoscopic Cholecystectomy
• Topical anti fog solution is applied to
the optical end of the telescope, which
may be either angled (30 degrees) or at
(0 degrees).

• The second 10-mm trocar port is

placed in the epigastrium about 1–2 cm
below the xiphoid, with its intra-
abdominal entrance site being just to
the right of the falciform ligament.
Laparoscopic Cholecystectomy
• The apex of the gallbladder fundus is
grasped with a ratcheted forceps (A)
through the lateral port. The
gallbladder and liver are then lifted
superiorly.

• Omental or other loose adhesions to

the gallbladder are gently teased away
by the surgeon .
Laparoscopic Cholecystectomy
• With gentle teasing and spreading
motions, the cystic duct and artery
are exposed .To minimize bile duct
injury the concept of the “critical
view of safety” is helpful.
• In the classic view the liver is seen
posterior to Calot’s triangle .
• If the dissection is difficult because
of inflammatory swelling and
scarring, the surgeon should consider
conversion to an open procedure.
Laparoscopic Cholecystectomy
• The cystic artery is cleared or a 1-
cm zone and its path followed onto
the surface of the gallbladder. The
clear zone is then secured with
metal clips both proximally and
distally.
• A metal clip is applied as high as
possible on the cystic duct where it
begins to dilate and form the
gallbladder.
Laparoscopic Cholecystectomy
• If no cholangiogram is to be
performed, then two clips are placed
on the proximal cystic duct and the
duct is divided.
Laparoscopic Cholecystectomy
• The cystic duct–gallbladder junction is
grasped with forceps through the
middle port and the gallbladder is
removed from its bed beginning
inferiorly and carrying the dissection
up the gallbladder fossa.
• Most surgeons score the lateral
peritoneum or a centimeter or so with
electrocautery and then elevate the
gallbladder from the liver bed.
Laparoscopic Cholecystectomy
• Appropriate traction, often to the sides,
is required to provide exposure of the
zone of dissection with an
electrocautery instrument between the
gallbladder and its bed.
Laparoscopic Cholecystectomy
• When the dissection is almost complete
and traction on the gallbladder still
allows superior displacement of the
liver with a clear view of the gallbladder
bed and operative site, the surgeon
should reinspect the clips on the cystic
duct and artery or their security and the
liver bed or any bleeding sites.
• The region is irrigated with saline and
the diluted bile and blood are aspirated
from the lateral gutter just over the edge
of the liver.
Laparoscopic Cholecystectomy
• A grasping forceps is passed through
the umbilical port so as to pick up the
end of the specimen in the region of
the cystic duct or the specimen
retrieval bag.
Laparoscopic Cholecystectomy
• After removal of the gallbladder and
final inspection of the abdomen, all
ports are removed and the sites closely
inspected or bleeding.

• The videoscope is removed and the

pneumoperitoneum is evacuated so as
to lessen postoperative discomfort.
 Intraoperative Cholangiogram
Recommendations:
• History of abnormal liver function tests
• History of pancreatitis
• Jaundice
• Large duct with small stones
• Dilated common bile duct (UTZ)

Brunicardi, F. C., & Andersen, D. K. (2019). Schwartz's

principles of surgery. In Schwartz's principles of surgery
(11th ed., p. 1413). New York: McGraw-Hill.
Intraoperative Cholangiogram
Junction of the cystic and common ducts is identified, bipolar scissors are
used to make a small incision in the cystic duct approximately 1 to 2 cm
from the common duct.

A soft silicone rubber cholangiogram catheter (No. 5 to 8 French gauge)

is used.

The catheter and connecting tubes are flushed with sterile saline to
remove any bubbles and the catheter is inserted gently into the cystic
duct.
Intraoperative Cholangiogram
As the cannulation is performed, saline
solution is injected continuously to avoid air
bubbles.

A tie or a large or medium-sized hemoclip is

employed to secure the cannula, confirming
that bile can be aspirated and that saline can
be injected easily without extravasation.
Intraoperative Cholangiogram
Avoiding introduction of air, the syringe of saline is exchanged for one containing
dilute or soluble contrast medium.

At this point, all packs are removed from the abdomen and any retractors are removed
from the operating field.

The use of operative fluoroscopy and image intensification allows controlled

instillation of contrast under gentle pressure to enable full opacification of the
extrahepatic biliary tree, confirming free flow of contrast into the duodenum and
filling of the right and left hepatic ducts to exclude the presence of any ductal calculi.
Intraoperative Cholangiogram
Should a normal cholangiogram be
obtained but contrast fails to enter the
duodenum:

• administration of CCK (20 mg/kg) or

glucagon (1 mg IV) → relax the sphincter
of Oddi sufficiently to allow the flow of
contrast into the duodenum.
Common Bile Duct Exploration
The ligamentum teres is divided by
doubly clamping and ligating the
obliterated umbilical vessel in its
free edge.

The hepatic flexure of the colon is

mobilized to expose the duodenum.
The peritoneum lateral to the
duodenum is incised with bipolar
diathermy scissors.
Common Bile Duct Exploration
Mobilization should be continued until
the non-dominant hand can be placed
easily behind the head of the pancreas to
feel the terminal CBD and ampulla.

A short longitudinal incision is made

with a No. 11 blade, usually following
placement of 4-0 polydioxanone
retaining sutures
Common Bile Duct Exploration
The choledochotomy should be extended
with the blade or sharp scissors to
approximately 1 cm in length
Common Bile Duct Exploration
Stones may be retrieved by gentle
irrigation of the duct with saline through
a soft rubber catheter.

A Fogarty balloon-tipped catheter can be

passed both proximally and distally,
inflating the balloon before the catheter
is gently withdrawn and until all the
stones and debris are cleared.
Common Bile Duct Exploration
Saline should be run freely into the duct.

Scope should not be forced beyond the central lumen of the ampulla

The right and left hepatic duct should be explored superiorly and any
stones retrieved.
Common Bile Duct Exploration
Flexible choledochoscope allows direct visualization and manipulation
under direct vision.
• If 5mm: A Fogarty catheter or wire basket.

Choledochoscopy to ensure clearance of the ductal system.

Common Bile Duct Exploration
Primary closure of the choledochotomy
or a T-tube can be placed to decompress
the duct and facilitate the removal of any
retained stones in the postoperative
period.

T-tube
• The back wall of the vertical stem should
be excised and a V-shaped wedge
fashioned at the junction of the limbs
Common Bile Duct Exploration
The limb is brought out normally
through the anterior abdominal wall
laterally so that subsequent radiologic
manipulation is possible.

T-limb is displaced to the upper limit of

the choledochotomy so that closure can
proceed from below using interrupted 4-
0 polydioxanone sutures
Common Bile Duct Exploration
+/- completion cholangiogram if adequate examination with
choledochoscopy.

Stones may be suspected falsely because of previous introduction of air

bubbles, and failure of contrast to enter the duodenum may result from
sphincter spasm.