accelerate recovery and reduce the hospital stay in patients following ... a needle, a 0.035-mm floppy guide-wire, a dilator, and a peel-away sheath. (Fig. 1A,B). Technique .... no comparative data, T-tube insertion after laparoscopic di- rect CBD ...
Surg Endosc (1997) 11: 1106–1110
Surgical Endoscopy © Springer-Verlag New York Inc. 1997
Transcystic biliary decompression after direct laparoscopic exploration of the common bile duct C. Hensman, G. Crosthwaite, A. Cuschieri Department of Surgery and Surgical Skills Unit, Ninewells Hospital and Medical School, University of Dundee, Tayside DD1 9SY, Scotland Received: 5 March 1997/Accepted: 15 May 1997
Abstract Background: A purpose-designed transcystic common bile duct (CBD) decompression cannula is described for use as an alternative to T-tube insertion following laparoscopic direct CBD exploration. This permits safe primary closure of the choledochotomy. Methods: Following direct supraduodenal laparoscopic clearance of large common bile duct stones, the biliary decompression cannula is inserted percutaneously inside its peel-away sheet over a guide-wire into the CBD via the cystic duct. When in place, the cannula is secured to the cystic duct by two catgut extracorporeal Roeder knots and the choledochotomy is then closed. The terminal multiperforated S-shaped segment of the Cuschieri biliary decompression cannula prevents postoperative dislodgement. Results: Transcystic decompression of the extrahepatic biliary tract using the Cuschieri cannula has been used in 12 patients who underwent laparoscopic supraduodenal CBD exploration for large or occluding stones. There was no instance of postoperative dislodgement of the cannula and all patients had effective drainage of the common bile duct (average 300 ml bile per 24 h). The procedure was uncomplicated in all but one patient who developed self-limiting leakage from the CBD suture line in the early postoperative period. The median hospital stay after surgery was 4 days, with a range of 3 to 10 days. The cystic duct decompression cannula was capped and sealed under an occlusive dressing at the time of discharge. Removal of the cannula was carried out without any complications as a day case 11–16 days after surgery. Conclusions: Transcystic biliary decompression is safe and effective. The experience with is use indicates that compared to T-tube drainage, transcystic decompression may accelerate recovery and reduce the hospital stay in patients following laparoscopic direct exploration of the CBD. Its insertion is less technically demanding than placing a Ttube through the choledochotomy. Transcystic decompres-
Correspondence to: A. Cuschieri
sion with complete primary closure of the CBD realizes the full benefits of the single-stage management of common bile duct calculi and permits confirmation of complete stone clearance after surgery. Key words: Common bile duct — Transcystic biliary decompression — Direct laparoscopic exploration
Several reported studies have revealed the feasibility, safety, and efficacy of open single-stage laparoscopic treatment of patients with gallstones who also harbor ductal calculi [1, 2, 6, 7, 10, 11, 14, 15]. The preliminary findings of a randomized, controlled clinical trial show documented advantages, i.e., reduced hospital stay and avoidance of unnecessary ERCP with single-stage surgical management compared to the two-staged approach [5]. Whenever possible, the transcystic technique is used to achieve ductal clearance laparoscopically, but when this fails, and in the presence of large occluding calculi, a laparoscopic supraduodenal exploration of common bile duct (CBD) is needed. Following clearance, most laparoscopic surgeons close the choledochotomy around a T-tube as in open surgery. This appears to delay recovery, and in the EAES study, the median hospital stay of patients treated by laparoscopic direct CBD exploration was 10 days as opposed to 5.5 days after transcystic clearance [5]. The use of a T-tube to drain the CBD following laporoscopic exploration is technically demanding and reduces the benefits of the minimal access approach. Primary closure of the CBD without decompression drainage is practiced by some laparoscopic surgeons but this is not considered orthodox practice for two reasons. In the first instance, manipulations inside the lower end of the CBD are followed by temporary obstruction due to periampullary edema in the first few days after surgery [9]. Secondly, primary closure without decompression precludes postoperative cholangiography to confirm complete ductal clearance.
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Fig. 2. The drainage cannula is threaded over the guide-wire into the peritoneal cavity.
a needle, a 0.035-mm floppy guide-wire, a dilator, and a peel-away sheath (Fig. 1A,B).
Technique of insertion and fixation of cannula
Fig. 1. a Cuschieri transcystic biliary decompression set. b Close-up of the S-shaped terminal segment.
For many years during open biliary surgery, we have practiced decompression of the CBD after direct exploration by inserting a cannula into the CBD followed by primary closure of the duct [3]. This practice has been extended to laparoscopic duct exploration. Initially, we used an infant enteric feeding Portex tube (Fr. 7) for this purpose [16] but encountered problems with dislodgement of the tube postoperatively in some patients. This led to the design of a laparoscopic cystic duct biliary decompression cannula which overcomes this problem and provides more efficient drainage. This paper reports our experience in patients undergoing laparoscopic direct CBD exploration with cystic duct decompression of the biliary tract and primary closure of the supraduodenal choledochotomy.
Patients and methods Laparoscopic CBD drainage catheter set The Cuschieri biliary decompression set (Cook Surgical, Bloomington, U.S.A) consists of a specially designed 1-m-long silicon cannula with a luer lock connection at the proximal end and a distal perforated S-shaped segment with a terminal opening. The S bend prevents postoperative dislodgement of the functional segment of the cannula from the CBD while the multiple perforations ensure efficient bile drainage. The cannula is available in three sizes—Fr. 5, 7, 8. The biliary decompression cannula was designed for percutaneous insertion and its deployment system consists of
Following supraduodenal exploration of the CBD and confirmation of stone clearance by flexible choledochoscopy, the needle and guide-wire are inserted through the parietes in a suitable site in the right flank. The needle is then removed, leaving the guide-wire in situ. The dilator with the peelaway sheath is introduced into the peritoneal cavity over the guide-wire (Fig. 2). The dilator is then replaced by the biliary decompression cannula, which is threaded over the guide-wire and through the peel-away sheath. A length of guide-wire (circa 5.0 cm) is inserted into the cystic duct and thence into the CBD, and the biliary decompression cannula is then railroaded by means of a grasper over it until the perforated S-shaped terminal segment is beyond the cystic–common duct junction (Fig. 3). The guidewire is then removed and a saline syringe is attached to the luer external fitting of the cannula. The position of the terminal segment of the decompression cannula inside the CBD is checked through the choledochotomy, and if correct, the cannula is fixed to the cystic duct and to the parietes. Fixation of the drainage cannula to the cystic duct is achieved by two Roeder 0-gauge chromic catgut knots (Fig. 4). The first is close to the cystic duct–CBD junction [12]. The second Roeder knot is placed a few millimeters further laterally. Saline irrigation through the cannula is maintained during the locking of the Roeder knots by the push rod to prevent overtightening and occlusion of the cannula. A loose loop of cannula is left between the cystic duct fixation point and the parietes before the cannula is secured externally to the skin near the exit hole by two nonabsorbable sutures.
Closure of the choledochotomy Saline irrigation is maintained during closure of the choledochotomy, which is carried out with interrupted or continuous 4/0 Polysorb (USSC, Norwalk, CT, USA) mounted on a ski needle using an intracorporeal microsurgical technique [4] (Fig. 5). On completion, the common duct is flushed through the transcystic cannula to check for leaks and a completion cholangiogram is performed. If this confirms ductal clearance, the cystic duct is transected between the lateral catgut ligature and the clipped neck of the gallbladder. A silicon subhepatic drain leads to the closed choledochotomy.
Patients Twelve patients, two males and three females, aged 54–72 years, all with large CBDs, underwent laparoscopic supraduodenal CBD during laparo-
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Fig. 3. Insertion of decompression cannula held in a grasper through the cystic duct over the guide-wire.
Fig. 4. Fixation of the biliary decompression cannula to the cystic duct by catgut Roeder knots.
scopic cholecystectomy with primary closure of the choledochotomy and decompression of the biliary tract by means of a cystic duct decompression cannula. All had clinical jaundice with raised alkaline phosphatase at the time of the intervention. Preoperative ultrasound examination confirmed a dilated intrabiliary tree. All patients were ASA category I or II and none had clinical evidence of ascending cholangitis. Two patients had undergone unsuccessful endoscopic stone extraction due to inability to cannulate the bile duct. Preoperative preparation was with intravenous cystalloid hydration, bladder catheterization, and forced diuresis with mannitol. An intramuscular injection of synthetic vitamin K analogue was administered 24– 48 h after surgery. All patients received single-dose antibiotic prophylaxis during induction of general anesthesia. The tube cholangiogram was repeated postoperatively in all the patients.
Results Operative outcome The triangle of Calot was dissected in a standard fashion utilizing the four-port Dundee technique [13]. When the
Fig. 5. Closure of the choledochotomy.
surgeon was confident of the anatomy, the cystic artery was double clipped and divided. Cystic duct fluorocholangiography using a digitized C-arm was performed using a Fr. 4 or 5 ureteric catheter inside a cholangiogasper (Storz, Tuttlingen, Germany) in all patients. The biliary radiological pathology is outlined in Table 1. The technique of CBD stone clearance varied. Only the anterior aspect of the CBD was dissected and stay sutures were not used. The peritoneum and underlying fascial layer over the supraduodenal portion of the CBD was divided and a longitudinal choledochotomy was performed. The size of the opening in the CBD was always smaller by approximately 30% than the largest stone in the individual patient. Because of the high elastin content of the CBD, a choledochotomy can be stretched to allow delivery of a stone. The advantages of a small choledochotomy include less devacularization and reduced suturing time. The ductal calculi were cleared from the CBD by various means. Bimanual compression of the duct from below using two atraumatic graspers with massage of the stones into and then out of the choledochotomy was successful in five; Fogarty balloon dislodgement occurred in six; and one patient required a visually guided Dormia basket extraction using a 5-mm flexible choledochoscope (Storz, Tuttlingen, Germany). Following ductal stone extraction, all patients had completion choledochoscopy, which indicated total clearance in 11 patients. In one patient a missed stone was located near the common hepatic bifurcation and was removed at the same procedure.
Postoperative course The cystic duct cannula was left on free drainage for the first 48 h utilizing a closed drainage system. The average output of bile via the biliary decompression cannula was 300 ml per 24 h period. The subhepatic drain was removed on the 3rd day in all but one patient (day 8). A postoperative cholangiogram was performed in all patients via the cystic duct cannula 48 h post surgery (Fig. 6). The cystic decompression cannula was sealed and cov-
1109 Table 1. Common duct pathology at operation Sex, age (years)
CBD diameter (mm)
No. of CBD stones
Stone size (mm)
F, 54 F, 62a M, 49 F, 68 F, 54 M, 69 F, 46 F, 72a F, 61 F, 52 F, 51 F, 57
15.0 12.0 10.0 20.0 15.0 18.0 11.0 18.0 12.0 15.0 11.0 16.0
1 4 3 8 3 1 5 6 2 7 4 3
20 8–15 6–12 10 5–11 15 10 6–15 8–10 10 8 12
a
Failed attempts at endoscopic stone extraction
ered with an occlusive dressing in 11 patients as the cholangiogram was normal and there was no bile drainage from the subhepatic drain. The subhepatic drain was removed the next day (3rd day). In one patient the cholangiogram demonstrated leakage from the CBD suture line. This was accompanied by bile drainage from the subhepatic drain. This complication was managed conservatively as ultrasound examination showed no internal collection and the patient was afebrile. The bile leakage dried up within 8 days. Another patient developed patchy atelectasis which progressed to a chest infection requiring antibiotic treatment. The median hospital stay was 4.0 days with a range of 3 to 10 days and 80% of patients were discharged within 5 days post surgery. The patients returned to hospital for removal of the cystic duct drainage cannula 11–16 days after surgery and were kept for observation in hospital for a period of 3–4 h. None developed any symptoms of bile leakage into the peritoneal cavity during this observation period or thereafter.
Discussion This experience with the Cuschieri cystic duct biliary decompression cannula as an alternative to T-tube drainage has demonstrated that the technique is safe and easy to deploy. The provision of an effective decompression of the biliary tract is demonstrated by a low suture-line bile leakage rate of 8% despite the narrow caliber of the system (Fr. 5–8). The placement of a T-tube after direct supraduodenal CBD exploration is technically demanding and time consuming. It carries a significant morbidity due to dislodgement and infection, which may delay discharge from hospital. Furthermore, T-tube drainage of narrow ducts can contribute to late stricture formation [8]. Although there are no comparative data, T-tube insertion after laparoscopic direct CBD exploration appears to detract from the advantages of the minimal access approach. The median postoperative stay of 10.5 days observed in the EAES trial [5] is indicative of this detrimental effect. Previous debimetric studies have documented a temporary hold-up at the lower end of the CBD due to sludge, fibrin debris, or edema following manipulations to extract ductal calculi [9]. Thus temporary decompression is advis-
Fig. 6. Postoperative cholangiogram.
able in the prevention of postoperative bile leakage from the choledochotomy suture line. In addition, the postoperative tube cholangiogram provides the only reliable means for detecting retained stones. Thus, although some surgeons have practiced primary repair after laparoscopic direct CBD exploration, this cannot be regarded as standard orthodox surgical practice. Decompression of the biliary tract by the transcystic cannula facilitates closure of the choledochotomy, because, contrary to T-tube insertion, there is no long tube in front of the suture line. The closure of the bile duct either by continuous or interrupted suturing is thus quicker and more precise. The cystic duct biliary decompression cannula also serves as a safe access to the CBD for subsequent imaging or intervention. If retained ductal stones are documented in the postoperative period, flushing, fluoroscopic basket ex-
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traction by the Burhenne technique, or lithotripsy all constitute viable management options. If endoscopic stone extraction is preferred, the insertion of a guide-wire through the cannula into the bile duct and then the duodenum will serve as an excellent guide for the endoscopic sphincterotomy. The cannula was designed specifically with this in mind. The cystic duct decompression cannula can also be placed in the CBD as a means of safe access in patients when there is doubt about the clearance of stones after transcystic exploration of the CBD.
6. 7. 8. 9. 10. 11.
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