CBD Laparoscopy ppt

Laparoscopic Common Bile Duct Surgery : 

Laparoscopic Common Bile Duct Surgery Dr John AC Thanakumar MS, MNAMS, FRCS, FRCS, FIAGES, Dip MIS Senior Consultant, Minimal Access, Bariatric and GI Surgery, Global Hospital, Chennai. www.lapsurgeon.org

Anatomy : 

Anatomy

Anatomic - US- Endosco : 

Anatomic - US- Endosco

CBD stones : 

CBD stones CBD stones in 10%in young, 25% in ages>65 CBD stones during IOC or US of CBD Pre op ERCP has problems

ERCP in CBD stones : 

ERCP in CBD stones ERCP 11-14% failure in CBD stones Morbidity of 5-10% Mortality of 0.02%-0.5% Overall 5% pancreatitis

Slide 6: 

Pre-or post operative ERCP for bile duct clearance in cholecystectomy for gallstones offers no apparent advantage over surgical exploration. Surgical versus endoscopic treatment of bile duct stones Martin DJ, Vernon D, Toouli J Cochrane review abstract,by The Cochrane Collaboration, The Cochrane Database of Systematic Reviews 2011 Issue 1

Primary CBD closure : 

Primary CBD closure 5 trials with 324 patients randomised: 165 to primary closure without stent and 159 to T-tube. Primary closure after common bile duct exploration seems at least as safe as T-tube drainage. Gurusamy KS, Samraj K. Primary closure versus T-tube drainage after open common bile duct exploration. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD005640. DOI: 10.1002/14651858.CD005640.pub2

Safety in Laparoscopic CBD Exploration : 

Safety in Laparoscopic CBD Exploration Safe and effective Lap CBD Exploration One stage for CBD stone and GB Removal Cheaper, less days in hospital

TransCystic Approach (TCBDE)- Indications : 

TransCystic Approach (TCBDE)- Indications <9 stones Stones distal to cystic duct-CBD junction Stones <6 mm

TCBDE- Contraindications : 

TCBDE- Contraindications Intra hepatic stones Stones above cystic duct CBD >7mm

TCBDE : 

TCBDE 85-95% can be managed with TCBDE Lavage with saline Fogarty Balloon catheters Biliary Baskets Choledochoscopic Direct Removal

Stones <4mm : 

Stones <4mm Saline flush and 1 mg IV glucagon 3-4 min later flush again with saline Repeat fluoro and cholangio <3mm stones may pass If not .......................

Fogarty Balloon : 

Fogarty Balloon Large stones, not cleared with saline 4F Fogarty transcystic beyond the stones, inflated and withdrawn Or retrieval basket via fluoroscopy, close basket slowly and withdraw with stone Completion cholangiogram

Choledochoscopy : 

Choledochoscopy Basket is used under direct vision Very successful Requires second camera, light source/monitor 5th port subcostally is useful for the scope 3mm C.scope/ureteroscope via guide wire/direct Along with LC, success in 95% cases

LCBDE(Choledochotomy) : 

LCBDE(Choledochotomy) Multiple stones >9 Stone Diameter >6mm Intra hepatic stones Cystic duct <4mm Distal or posterior cystic duct entrance Surgeon with lap suturing skills

LCBDE- Video : 

LCBDE- Video http://www.youtube.com/watch?v=Rv05oHuv3Lk

Also useful in : 

Also useful in CBD stones >8 mm Failed ERCP Poor availability of ERCP Patients after Billroth II gastectomy LCBDE safe with lower morbidity and mortality compared to ERCP One stage management with lap chole

Complications of ERCP and CBD Exploration : 

Complications of ERCP and CBD Exploration Incomplete clearance Pancreatitis Bile Leak Stricture

Laparoscopic Ultra Sound for CBD assessment : 

Laparoscopic Ultra Sound for CBD assessment Lap US is the stethoscopic of the surgeon in the era of endoscopic surgery US visualizes structures below visible surface Lap US and cholangiogram are complementary Natheniel J Soper Laparoscopic Ultrasound for Assessment of the CBD

Indications-Laparoscopic Choledocho Duodenostomy : 

Indications-Laparoscopic Choledocho Duodenostomy In selected CBD obstruction-Chr. Pancreatitis, Stricture Mandatory CBD >1.5 cm

Contraindications-Lap Choledocho Duodenostomy : 

Contraindications-Lap Choledocho Duodenostomy CBD <1.5 cm Ac inflammation of Duodenum/CBD Not carcinoma of pancreatic head

Choledocho duodenostomy : 

Choledocho duodenostomy Open Atlas of Upper GI and HBS- Pierre Alain Clavier, et al

Technical considerations : 

Technical considerations 2.5 cm anastamosis of stoma No tension on anastamosis Choledochotomy far distal on CBD Duodenal wall must be healthy Kocherization is optional

Slide 24: 

Atlas of Upper GI and HBS- Pierre Alain Clavier, et al Surgical Technique- Open

Laparoscopic Choledo Duodenostomy : 

Laparoscopic Choledo Duodenostomy Laparoscopic Surgery of the abdomen Bruce MacFayden

Incise on CBD and D1 : 

Incise on CBD and D1 Laparoscopic Surgery of the abdomen Bruce MacFayden

Posterior Suture : 

Posterior Suture Laparoscopic Surgery of the abdomen Bruce MacFayden

Post wall suture completed : 

Post wall suture completed Laparoscopic Surgery of the abdomen Bruce MacFayden

Side to side completed : 

Side to side completed Laparoscopic Surgery of the abdomen Bruce MacFayden

Lap Choledocho DuodenostomyVideo : 

Lap Choledocho DuodenostomyVideo http://www.youtube.com/watch?v=ToUfsVOyhmE

Choledocho jejunostomy : 

Choledocho jejunostomy Atlas of Upper GI and HBS- Pierre Alain Clavier, et al

Laparoscopic Roux en Y Choledochojejunostomy : 

Laparoscopic Roux en Y Choledochojejunostomy CBD < 1.5 cm To eliminate tension on anastamosis To divert food stream To prevent stump syndrome and cholangitis In inoper cancer where >6 month expectancy

Surgical Technique of Laparoscopic Roux Choledochojejunostomy : 

Surgical Technique of Laparoscopic Roux Choledochojejunostomy Create first Roux jejunal loop Mobilize lower CBD and staple divide it Remove proximal staples on CBD CBD-End to side CBD to jejunum In single layer suture Jejuno jejunal stapled anastamosis

Laparoscopic Choledocho jejunostomy : 

Laparoscopic Choledocho jejunostomy Laparoscopic Surgery of the abdomen Bruce MacFayden

End to Side- Stays : 

End to Side- Stays Laparoscopic Surgery of the abdomen Bruce MacFayden

Posterior Wall Completed : 

Posterior Wall Completed Laparoscopic Surgery of the abdomen Bruce MacFayden

Completed End to Side : 

Completed End to Side Laparoscopic Surgery of the abdomen Bruce MacFayden

Stays for Jejuno Jejunostomy : 

Stays for Jejuno Jejunostomy Laparoscopic Surgery of the abdomen Bruce MacFayden

Stapled Jejuno Jejunostomy : 

Stapled Jejuno Jejunostomy Laparoscopic Surgery of the abdomen Bruce MacFayden

Contact Details : 

Contact Details Email: drjact@gmail.com Mob:09443709158 www.lapsurgeon.org Videos at YouTube; search under dr john thanakumar

Slide 41: 

Thank you