Laparoscopic common Laparoscopic common bile duct exploration bile duct exploration

LCBDE)LCBDE)))

introductionintroduction

Common bile duct stones (CBD) stones may occur in 3% to 14.7% of all patients for whom cholecystectomy is preformed

Schirmer et al., 2005

introductionintroduction

Different methods have been used for the treatment of (CBD) stones but the suitable therapy depends on conditions such as patient’ satisfaction, number and size of stones, and the surgeons experience in laparoscopy.

(Carr-Locke, 2006.)

Anatomy Of The Extra hepatic Anatomy Of The Extra hepatic Biliary SystemBiliary System

The extrahepatic bile ducts are represented by • the extrahepatic segments of the right and left

hepatic ducts joining to form the biliary confluence and

• the main biliary channel draining to the duodenum.

• The accessory biliary apparatus, which constitutes a reservoir, comprises the gallbladder and cystic duct

(Blumgart and Hann, 2007.)

(Ellis, 2006.)

Anatomy Of The Extra hepatic Anatomy Of The Extra hepatic Biliary SystemBiliary System

Common Bile Duct (Ductus Choledochus) • The common bile duct begins at the union of the cystic

and common hepatic ducts and ends at the papilla of Vater in the second part of the duodenum

• The common bile duct can be divided into four portions or segments

1. The supraduodenal portion 2. the retroduodenal portion 3. the pancreatic portion 4. the intramural portion

(Skandalakis et al., 2000(.

Classification and incidence of Classification and incidence of CholedocholithiasisCholedocholithiasis

Primary:Primary bile duct stones are formed in the intrahepatic or extrahepatic bile ducts. They are more prevalent in Asian populations. These stones usually are brown pigment stones. Bacterial colonization of bile and bile stasis play important roles in the pathogenesis of these stones

Secondary bile duct stonesIn the Western world, most stones in the common bile duct arise from the passing of gallbladder stones into the common bile duct. Stones in the common duct occur in 10% to 15% of people who have

gallbladder stones .

(Ko and Lee, 2002.)

Pathophysiology of Bile Duct Pathophysiology of Bile Duct ObstructionObstruction

Bile duct obstruction can affect hepatic hemodynamics significantly. In general, liver blood flow (LBF) is reduced in the presence of chronic biliary obstruction. Reduction of LBF in this setting may contribute to hepatic dysfunction. Conversely, acute increases in bile duct pressure after obstruction result in a reactive increase in LBF, which may represent an attempt by the liver to maintain adequate function against an increase in the pressure gradient opposing secretion and excretion of bile

(Blumgart et al., 2007.)

Biliary-Induced Hepatic AtrophyBiliary-Induced Hepatic Atrophy

The molecular mechanisms involved in biliary obstruction leading to hepatic atrophy are much more centered on apoptosis, with little or no involvement of acute necrosis. Cholestasis results in the accumulation of toxic bile salts, which induce apoptosis

(Gujral et al, 2004.)

Clinical PictureClinical Picture

• Asymptomatic,• sudden toxic cholangitis,• biliary colic • pruritus • jaundice• pancreatitis

(Lauter and Froines, 2000.)

Blood TestsBlood Tests

Patients presenting with CBDS often have • cholestatic liver function tests (LFT’s). • Elevated serum gamma glutamyl

transpeptidase (GGT) and• Elevated serum alkaline phosphatase

(ALP) were the most frequent biochemical abnormalities in patients with symptomatic choledocholithiasis (increased in 94% and 91% of cases, respectively)

Caddy and Tham, 2006.)

Imaging ModalitiesImaging Modalities

Transabdominal ultrasound (TUS)

Computed tomography (CT):Magnetic Resonance Cholangiopancreatography (MRCP) :

Endoscopic retrograde cholangiography (ERC) Endoscopic Ultrasound (EUS)