Choledochotomy

Choledochotomy

When faced with a patient with cholangitis due to stones in the CBD, and minimally invasive techniques for stone extraction are not possible, the surgeon must undertake laparotomy , drain the CBD and remove the stones through a longitudinal incision in the duct. When the duct is clear of stones, on-table - or - - - lo Hospital, Milan, Italy .

Figure 71.34 This patient presented with jaundice 4 days after laparo

scopic cholecystectomy. The duct contained multiple stones. (b) (a) Figure 71.35 (a) Endoscopic sphincterotomy; (b) extraction of a stone from the bile duct through an ampulla (courtesy of Dr Amit Maydeo, Mumbai, India).

choledochoscopy should be performed to confirm clearance. A T-tube is inserted and the duct closed around it; the long limb is brought out on the right side and bile is allowed to drain externally . When the bile becomes clear and the patient has recovered, a cholangiogram is performed. If residual stones are found, the tube is left in place for 6 weeks so that the track is ‘mature’. The radiologist can then use the track for percuta neous removal of the stones (Burhenne) ( Figure 71.36 ). Once the radiologist has removed the tube, the track will close and the patient will recover. Such residual small stones are now usually managed with endoscopic methods.

Figure 71.36 Extraction of a stone from the common bile duct by the Burhenne technique. (b) A steerable catheter is manipulated into the duct and a basket placed around the stone. T-tube track.