Tec h n i c a l A s p e c t s o f B i l e D u c t

E v aluatio n an d E xp l o r a ti on
Sean B. Orenstein, MD, Jeffrey M. Marks, MD,
Jeffrey M. Hardacre, MD*

KEYWORDS
 Common bile duct exploration  Laparoscopic  Open  Cholangiogram  ERCP

KEY POINTS
 Choledocholithiasis is a common manifestation of biliary disease.
 Intraoperative cholangiography can be performed in a variety of ways.
 Common bile duct exploration can be safely performed but necessitates an advanced
level of surgical experience to limit complications and improve success.
 An appropriate algorithm based on available resources and the physician skill set is vital
for safe and effective management of choledocholithiasis.
 Endoscopic retrograde cholangiopancreatography requires the availability of an
advanced endoscopist as well as significant equipment and resources.
 Current training of young surgeons is limited for open biliary procedures and common bile
duct explorations. Educational guidelines are necessary to reduce this educational gap.

INTRODUCTION

More than 20 million Americans have some form of gallstone disease. Of these, 5% to
20% present with common bile duct (CBD) stones, with the elderly at greatest risk.1–3
The presence of CBD stones can lead to a range of upstream and downstream effects
throughout the biliary tract including obstructive jaundice, cholecystitis, cholangitis,
and pancreatitis. The spectrum of morbidity from these diseases varies greatly,
ranging from asymptomatic choledocholithiasis to critically ill cholangitis. Prompt
identification and treatment are necessary to reduce the severity of illness caused
by bile duct stones and subsequent biliary obstruction and ascending infection.
Managing choledocholithiasis can be challenging from an organizational standpoint.
Method and timing of cholangiography, timing of operative intervention, potential need
for bile duct exploration, and cooperation between surgery and gastroenterology
all present challenges to the management of patients with choledocholithiasis.

Disclosure: The authors have no financial disclosures.

University Hospitals Case Medical Center, Cleveland, OH, USA
* Corresponding author. Department of Surgery, UH Case Medical Center, 11100 Euclid Avenue,
Cleveland, OH 44106.
E-mail address: [email protected]

Surg Clin N Am 94 (2014) 281–296

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282 Orenstein et al

Often-overlooked critical aspects of bile duct stone management are resource use
as well as availability of a skilled endoscopist. A separate endoscopy team with at least
1 or 2 nurses/technicians is typically necessary for endoscopic retrograde cholangio-
pancreatography (ERCP), whether it be performed before, during, or after surgery.
Specialized equipment is necessary for successful diagnostic and therapeutic endo-
scopic cholangiography. The experience of the endoscopist also affects the timing of
cholangiography, because the clinician’s skill set may dictate whether preoperative
or postoperative cholangiography is warranted.
The skill level of the surgeon is another critical aspect affecting bile duct stone
management. Although most surgeons complete residency with excellent training in
laparoscopic cholecystectomy, most are inadequately trained for laparoscopic or
open bile duct exploration. In addition, open cholecystectomies are also rarely
performed in residency, with most chief residents having performed only 10 open
cholecystectomies.4

PREOPERATIVE CHOLANGIOGRAPHY
Indications
There are a variety of scenarios in which preoperative cholangiography may be war-
ranted. Such entities may overlap and include cholangitis, biliary pancreatitis, persis-
tent jaundice, uncomplicated choledocholithiasis, benign stricture, and periampullary
neoplasm. Of these, ascending cholangitis represents the most severe disease and
warrants urgent biliary decompression, preferably by endoscopic means. However,
if ERCP is not possible, percutaneous or open biliary decompression is indicated.
Mild gallstone pancreatitis can typically be initially observed with trending of pancre-
atic enzymes; however, severe biliary pancreatitis with ductal disruption is another
indication for urgent ERCP. Although variable, liver function tests can aid in diagnosing
common duct disorders, but specific patterns and levels are debatable.5–7
The use of preoperative cholangiography may depend on the resources available in
a particular health care setting. The absence of a skilled interventional endoscopist
means that the surgeon is of the utmost importance in bile duct stone management.
Not having the luxury of a skilled therapeutic endoscopist may encourage attempts
at preoperative cholangiography. The finding of a bile duct stone may alter a surgeon’s
operative approach and provide for better preoperative counseling to the patient.
Such a circumstance is preferable to finding a bile duct stone during surgery and
deferring to a postoperative ERCP, only to have it fail. In addition, for patients present-
ing with biliary pancreatitis or choledocholithiasis who are unable to undergo chole-
cystectomy, dedicated ERCP for biliary sphincterotomy may be a viable option.

Magnetic Resonance Cholangiopancreatography Versus ERCP

With regard to the method of preoperative cholangiography, 2 common entities exist:
magnetic resonance cholangiopancreatography (MRCP) and ERCP. Both are useful
adjuncts in the diagnosis of biliary stone disease, and they each have appropriate
indications. Although MRCP can provide anatomic detail of the biliary tract, it is only
a diagnostic tool and, as such, cannot provide any direct therapeutic benefit.
ERCP is indicated when therapeutic interventions are needed, such as in acute
cholangitis, biliary pancreatitis with ductal obstruction, and uncomplicated choledo-
cholithiasis. However, ERCP should not be performed until a surgical plan is in place.
This delay allows more efficient use of hospital resources, decreased hospital length
of stay, and greater clarity for the patient as well as surgical/medical care providers.
Often overlooked by nonendoscopists, ERCP uses significant resources and
 Bile Duct Evaluation and Exploration 283

personnel to perform the procedure compared with MRCP. ERCP requires multiple
pieces of equipment including a side-viewing endoscope, video and lighting equip-
ment, CO2 gas (if available) and connectors, guidewires, sphincterotomes, an electri-
cal source such as ERBE or standard cautery, balloon catheters, lithotripsy devices,
multiple sizes of stents, and fluoroscopic devices. Depending on the facility it may
also require involvement of anesthesia, an endoscopic technician, nursing staff, and
a radiology technician, in addition to the advanced endoscopist. A technical descrip-
tion of the ERCP procedure is given elsewhere in this issue.
However, MRCP can provide greater anatomic detail of surrounding organs and tis-
sues, making MRCP more useful for evaluating persistent jaundice and diagnosing
periampullary or biliary malignancies. Because many patients with biliary malignancies
proceed to resection, ERCP may be more helpful in late-stage disease in which palli-
ative biliary stenting is necessary, or if preoperative temporary stenting is required in
earlier stage disease.
The risks of MRCP are minimal, with some restrictions for patients with implanted
metallic objects or metallic foreign bodies that are not safe for magnetic resonance
imaging (MRI). In addition, caution should be used when performing MRI with
gadolinium on patients with severe renal disease, especially on dialysis, because
there is a small risk of post-MRI nephrogenic fibrosing dermopathy.8 In contrast,
ERCP has a more extensive risk profile including acute pancreatitis (2.4%–4%),
bleeding (0.3%–1.4%), ascending biliary infection (1.4%), perforation (0.6%), as
well as a mortality of 0.2% to 0.9%.9–11

INTRAOPERATIVE CHOLANGIOGRAPHY

Cholangiography is a common adjunct to cholecystectomy, with approximately

30% of patients undergoing cholecystectomy receiving an intraoperative cholangio-
gram (IOC).12,13 There are 3 principal goals with intraoperative cholangiography: iden-
tify ductal anatomy, confirm the presence or lack of stones, and education/training.
Although some surgeons prefer to perform cholangiograms routinely, others are se-
lective on which patients receive an IOC. When there is any doubt regarding ductal
anatomy during dissection, a cholangiogram is warranted to further delineate cystic
and/or common duct anatomy.
There are clear indications for intraoperative cholangiography based on preopera-
tive data. Jaundice and increased liver function tests often indicate concurrent or
recent choledocholithiasis. Persistent increased levels with or without accompanying
jaundice should warrant an IOC.
Likewise, increased pancreatic enzymes in the setting of cholelithiasis indicate a
passed or passing common duct stone. In our practice, surgical intervention for gall-
stone pancreatitis (cholecystectomy) is delayed until amylase and/or lipase levels are
trending down, although complete normalization is not necessary as long as the pa-
tient’s symptoms from pancreatitis are resolving. Although IOC should be considered
for gallstone pancreatitis to ensure no remaining common duct stones persist, ERCP
is typically not warranted, because the stone has likely passed into the duodenum.
Cholangiography is also indicated for radiographic evidence of biliary obstruction.
Such obstruction can be manifested by a dilated biliary tree or the presence of com-
mon duct stones seen on ultrasonography, computed tomography, or MRI. However,
ductal dilatation without the presence of gallstones should warrant further evaluation
for a possible neoplastic source of biliary obstruction Box 1.
There is still debate about routine versus selective use of intraoperative cholangiog-
raphy. Proponents of either method can cite numerous studies to justify their
284 Orenstein et al

Box 1
Indications for IOC

History of or current jaundice

Increased liver function tests
Increased pancreatic enzymes
Ductal dilatation on imaging
CBD stones seen on imaging

positions. For example, studies favoring routine use argue that IOC allows earlier
detection of ductal injuries, stones, and other associated anomalies.14,15 Fig. 1 shows
choledocholithiasis found incidentally on routine IOC during elective cholecystec-
tomy. The earlier detection of common duct disorders may lead to quicker operative
management with a reduced need for postoperative interventions, such as ERCP. In
contrast, Horwood and colleagues16 argue that selective use of IOC for only the indi-
cations listed earlier provide a more rational directed approach given the high positive
predictive value for selective indications, as well as low rate of common duct disorders
for asymptomatic patients not meeting selective criteria. A recent Medicare database
study of elderly patients concluded that CBD injury rates were equivalent with or
without IOC. Despite a significantly higher CBD injury rate without IOC on initial anal-
ysis, the investigators found no association between IOC and CBD injury after addi-
tional statistical analysis.17 Others argue that even if the overall risk of CBD injury is
not reduced with routine IOC, the severity of injury and resultant sequelae are
mitigated with the use of IOC.14,18
In addition, some clinicians have questioned the routine use of IOC from a cost-
analysis perspective. Studies have shown that the use of IOC adds more than the

Fig. 1. Routine intraoperative cholangiogram during elective cholecystectomy showing

multiple filling defects in the distal CBD. Note the normal CBD diameter and contrast
flow into the duodenum. The patient underwent postoperative ERCP following cholecystec-
tomy with drain placement.
 Bile Duct Evaluation and Exploration 285

average surgeon realizes, with an added approximately $700 to 900 or more per
case.12,13 However, there is still no definitive conclusion about whether routine or se-
lective IOC provides the most effective and efficient treatment of patients with biliary
disease. Regardless of cholangiography use, it is still vital to adhere to standards of
biliary dissection, including obtaining the critical view of safety in order to limit
misidentification of cystic duct anatomy and minimize biliary injury.19,20

Ultrasound Cholangiography
Ultrasonography-based techniques for cholangiography provide a safe and accurate
method of detecting CBD stones with multiple benefits, including elimination of the ra-
diation and contrast exposure associated with fluoroscopic cholangiography.21–23
Compared with fluoroscopic cholangiography, ultrasonography is highly sensitive
and specific in identifying CBD stones and ductal dilatation (83%–100% sensitivity
and 98%–100% specificity).21,24,25 Ductal diameter and thickness can be accurately
measured, and adjacent anatomy, including vascular structures, bowel, and
pancreas, can be visualized. In addition, compared with fluoroscopic cholangiog-
raphy, ultrasonography is more cost effective, with an ultrasonography machine
costing approximately US$40,000 to US$75,000 compared with a C-arm and supplies
costing US$500,000 or more.21,22,25 However, there are limitations to such a tech-
nique. First, ultrasonography is operator dependent with a large learning curve, and
the use of ultrasonography is not frequently taught in residency. From an anatomic
standpoint, difficulty can arise when differentiating structures such as the CBD from
the cystic duct. Stones are typically well visualized, although they can display acoustic
shadowing, which may, in turn, lead to difficulty in structural identification. In addition,
the use of ultrasonography provides only diagnostic evaluation without any therapeu-
tic benefits.

Ultrasonography technique
The camera should be moved to the epigastric port to allow introduction of the
laparoscopic ultrasonography probe via the 12-mm umbilical port. Imaging quality
may be improved with the placement of saline over the liver and porta hepatis. The
liver is then retracted cephalad and the ultrasonography probe is placed over the
porta hepatis; the probe is aimed toward the foramen of Winslow and perpendicular
to the hepatoduodenal ligaments. As the probe is swept distally toward the duo-
denum, correct orientation is displayed as the so-called Mickey Mouse silhouette,
with the head as the portal vein and the ears as the CBD and hepatic artery in cross
section.25 The probe is then swept proximally to visualize the common hepatic and
left/right hepatic ducts and can be rotated 90 to view the ducts in cross section
and longitudinally. In addition, the probe can be placed directly over the liver to
visualize the left and right hepatic ducts and the confluence into the common he-
patic duct. By sweeping along the CBD the takeoff of the cystic duct can be iden-
tified, ductal diameter can be measured, and the presence of stones can be
visualized.23,25

Fluoroscopic Cholangiography
Although ultrasonography can diagnose CBD disorders, fluoroscopic cholangiog-
raphy has the benefit of providing a route for therapeutic intervention. Using fluoro-
scopic IOC, stones can be identified with greater than 95% sensitivity and
specificity, 5% false-positive, and 1% false-negative rate with some surgeons,26
although these rates are highly variable depending on the study.27 Because this
technique is still widely used, many surgeons have acquired the required skill set
286 Orenstein et al

for IOC in their residency training. However, compared with ultrasonography, more
risks are present, including radiation and contrast exposure, as well as perforation
or other injury to the duct.

Fluoroscopic technique
Before commencing cholangiography it is important that all supplies are available and
ready. A C-arm, radiology technician, and radiation protective gear (lead gowns/
aprons, thyroid shield) should be available at the start of the procedure. The operating
table should be oriented in a way that allows the bottom component of the C-arm to
move freely under the upper abdomen and lower thorax. The surgeon, resident(s) or
assistant, and scrub technician should be knowledgeable about the cholangiogram
catheters available at their institution. Once connected, the cholangiogram catheter
system should be thoroughly flushed with saline; any air within the system can lead
to false-positives during cholangiography. A 3-way stopcock can be set up with 1 sy-
ringe of saline and 1 of full-strength water-soluble contrast; this allows for limited
exchanging of syringes and reduces air entry. The syringes should be labeled and
clearly identified to ensure proper luminal contrast injection during fluoroscopy.
After cystic duct dissection and clear visualization of the critical view, a single metal
clip is placed at the cystic duct–gallbladder junction. Using sharp laparoscopic scissors
a small cystic ductotomy is made; this should be only large enough to allow the catheter
to be inserted. One side of the Maryland grasper can be gently inserted as a guide. The
cholangiogram catheter can be placed through various ports based on anatomic align-
ment with the cystic duct, or even a new port if all other ports are necessary for retrac-
tion. With gentle traction of the gallbladder neck inferiorly to straighten the cystic duct,
the catheter is placed though the ductotomy and is secured in place with either an intra-
luminal balloon or laparoscopic cholangiogram grasper. The catheter is then flushed
with saline to check the seal and flow. Although a minimal amount of saline extravasa-
tion is acceptable, a large rush of saline from the ductotomy should prompt replace-
ment. Saline should flow easily without the need for excessive pressure on the
syringe. If there is difficulty pushing the syringe without an active leak, the catheter
may be against a spiral valve of Heister or the cholangiogram clamp may be on too tight,
both of which warrant small incremental adjustments. Care is taken to remove all
accessory instruments under direct visualization with gentle resting of the gallbladder
down on the porta hepatis, followed by removal of the laparoscope.
The sterilely draped C-arm is brought in and spot radiographs are performed to
check proper orientation and positioning, with the cholangiogram catheter slightly
to the left and lower center of the screen. Using live fluoroscopy, contrast is rapidly
injected. Cholangiography should not be considered complete until the entire biliary
tree is visualized, including the cystic duct, the left and right hepatic ducts, and the
common hepatic duct and CBD, and contrast is seen filling the duodenum (Fig. 2).
Lack of filling of any of these structures should prompt reevaluation. Any filling defects
warrant repeat cholangiogram after thoroughly flushing the system with saline to wash
out any air or gas bubbles (see Fig. 2). At times, rapid filling into the duodenum can
result in limited proximal duct filling. Placing the patient in Trendelenburg position
can assist with gravity-induced proximal duct filling. Also, the administration of 1 to
2 mg of intravenous (IV) morphine can induce sphincter of Oddi contraction, thereby
providing added back pressure for improve proximal filling. In contrast, if no duodenal
filling is seen, 1 mg of IV glucagon can be administered for sphincter of Oddi relaxa-
tion. Confirmation of filling a defect such as a stone warrants CBD exploration (CBDE)
or ERCP, as discussed later. Large-volume contrast extravasation may indicate ductal
transection, and lack of proximal duct filling despite performing the aforementioned
 Bile Duct Evaluation and Exploration 287

Fig. 2. (A) Intraoperative cholangiogram showing an air/gas bubble in the common hepatic
duct just above the cystic duct–CBD junction. (B) Complete cholangiogram showing resolu-
tion of air/gas bubble after flushing system. The biliary tree is visualized including the cystic
duct, the left and right hepatic ducts, and the common hepatic duct and CBD, and contrast is
seen filling the duodenum.

maneuvers may indicate CBD ligation, both of which warrant urgent operative explo-
ration. If normal, the cholangiogram catheter is removed and the cholecystectomy is
completed per routine technique. If possible, confirmatory images showing comple-
tion cholangiogram with or without filling defects should be saved and sent to radi-
ology for documentation purposes.
If cystic duct anatomy is not clearly identified or there is significant inflammation, it
may be possible to perform the cholangiogram via the gallbladder. This procedure is
performed in manner nearly identical to the transcystic technique, but it is initiated by
making a small incision into the neck or body of the gallbladder. An endoloop can be
placed around the cholangiogram catheter to help limit extravasation of bile around
the catheter. If the gallbladder has significant edema and inflammation, an alternative
approach involves partial dissection of the fundus followed by fundal cholecystotomy;
this allows the endoloop to encircle the fundus and catheter for a tighter seal.
If the cholangiogram documents a common duct stone, therapeutic intervention is
warranted. Management of CBD disorder, including CBDE performed laparoscopi-
cally or with conversion to open procedure, is discussed later. As an alternative,
ERCP may play a role either during or after surgery to alleviate the obstruction and
allow proper biliary drainage into the duodenum.

CBDE
Laparoscopic CBDE
Since the advent of laparoscopy, techniques have evolved to enhance or mirror those
of the open counterpart. Although laparoscopic and open cholecystectomy differ
significantly in procedural steps, laparoscopic CBDE uses virtually the same tech-
nique and steps as the open approach. Routes of entry into the biliary tract include
transcystic, transcholecystic, or transcholedochal. Regardless of entry route, gall-
bladder dissection should be performed in standard fashion with the critical view ob-
tained and clear visualization of biliary structures. Because of the technical challenges
and time commitment with laparoscopic CBDE (LCBDE), the operating staff and anes-
thesia team should be apprised in order to prepare for a longer procedure and need for
288 Orenstein et al

sedation/paralytics so that the laparoscopic working space is not reduced. Clinicians

may also consider performing a complete cholecystectomy or near-complete dissec-
tion of the gallbladder so that there is limited manipulation of the gallbladder and cystic
duct following completion of the CBDE.
It is of utmost importance to obtain the proper equipment and supplies in order to
limit wasted time in setting up for the procedure. Some facilities have a designated
CBDE cart or area in central supply to diminish delays and frustration as to necessary
supplies.28 In addition, all-in-one disposable kits are manufactured to reduce supply
confusion. A supply list has been provided that contains the essential elements neces-
sary for LCBDE (Box 2).

Transcystic technique
The principal benefits of transcystic CBDE are that access has already been achieved
from the initial cholangiogram, and choledochotomy is avoided, thus eliminating the
need for suture repair of the CBD and reducing possible complications from CBD
manipulation (eg, leak or stricture). However, this technique is disadvantaged for
proximal or multiple stones, stones larger than 5 to 7 mm, and tortuous or long cystic
ducts. All steps should be performed under fluoroscopy in order to monitor wire and
equipment location as well as to evaluate the progress of stone extraction.
1. Administer 1 mg of IV glucagon before the start of exploration.
2. Ensure that the cholangiogram catheter is well flushed with saline and all air
bubbles have been evacuated.
3. Flush CBD with saline, which may be sufficient for small stones (<4 mm) to pass
through the papilla. A follow-up cholangiogram may be performed to inspect for
residual stones.
4. Advance flexible-tip guidewire into CBD.

Box 2
Supply list for laparoscopic CBDE

Glucagon, 1 mg
Additional 5-mm laparoscopic trocar
Fluoroscopy with C-arm
Radiation protective gear
Sharp laparoscopic scissors
Cholangiogram catheter
Guidewire
Saline
Water-soluble contrast
Fogarty balloon catheters, 4 or 5 Fr
Flexible choledochoscopes, 3 and 5 mm
Additional light and video source
Extraction basket
T tubes, 10 and 14 Fr
Resorbable monofilament suture (eg, 4-0 or 5-0 polydioxanone [PDS])
Laparoscopic suturing instruments
 Bile Duct Evaluation and Exploration 289

5. Using a balloon catheter, dilate the cystic duct to approximately 5 to 7 mm in a

slow, controlled fashion, taking care to limit cystic duct dilatation to less than
the CBD diameter.28 This maneuver allows the passage of large instruments,
such as a choledochoscope, into the CBD.
6. The stones can be extracted in one of 2 ways: retrograde with a wire basket or
antegrade using a balloon catheter.
7. A basket retrieval system is used to extract the stones in a retrograde fashion
through the cystic duct. Care needs to be taken to encompass the stone(s) with
the basket and to avoid dragging stones or stone fragments higher into the hepat-
ic biliary tree.
8. If an antegrade route is chosen, the first step should be to perform a dilation of the
papilla to allow passage of stones and minimize tearing of the papillary tissue and
adjacent ducts with the stones. However, the risks of bleeding, ductal trauma, and
pancreatitis are still present with these maneuvers. After papillary dilatation, the
balloon is inflated proximally in the duct and advanced in an antegrade direction
to push the stones and debris into the duodenum.
9. Flushing with saline may assist clearing out residual fragments and debris.
10. If available, lithotripsy may be used to break up stones to allow easier retrieval and
passage.
11. Endoscopic guidance may also be used to visualize papillary dilatation, confirm
passage of stones, or assist with stone extraction by passing the wire through
the papilla toward the endoscope. This rendezvous procedure should only be per-
formed with the assistance of an advanced endoscopist to limit subsequent
injuries.
12. As an option, a 3-mm or 5-mm choledochoscope is used to visualize the duct. Un-
der direct visualization, wire basket retrieval, complete clearance of stones, and
biliary injury can be evaluated. One drawback is its limited ability to visualize
and clear proximal duct stones.
13. Additional saline flushing should be performed to clear out residual debris and
stone fragments from catheter or equipment manipulation.
14. A completion cholangiogram should always be performed to document clearance
of the biliary tract and to evaluate for ductal injury or leak.
15. Following removal of any catheters or scopes the cystic duct is ligated. We prefer
to use an endoloop for ligation to reduce cystic stump leak, because ampullary
spasm can lead to back pressure of bile.
16. Likewise, a Jackson-Pratt or Blake drain is left in place for a few days after surgery
in case a leak should occur.

Transcholecystic technique
A transcholecystic approach may be attempted if transcystic approaches are unsuc-
cessful, or in place of a transcystic approach. Such an approach may be warranted if
the cystic duct is not clearly identified or the anatomy is distorted. This technique in-
volves making a small incision into the neck or body of the gallbladder, or the fundus
as described earlier. The use of an endoloop around the cholangiogram catheter may
help limit extravasation of bile around the catheter. Through the cholecystotomy, the
CBDE is performed in the manner described earlier for the transcystic approach.

Choledochotomy technique
If unsuccessful with transcystic or transcholecystic stone extraction, clinicians must
proceed with either the choledochotomy technique or ERCP. Laparoscopic explora-
tion via choledochotomy should only commence if the surgeon has had prior
290 Orenstein et al

experience, because the potential for postoperative morbidity is severe if complica-

tions arise. The surgeon should be skilled with handling of the CBD and laparoscopic
ductal suturing, as well as being knowledgeable about the necessary equipment.
Choledochotomy should only proceed if there is favorable anatomy and minimal
inflammation. CBDE through this route requires a dilated duct of at least 8 to
10 mm, because smaller ducts have increased risk of iatrogenic injury including
rupture and are more likely to stricture at the ductotomy site.28,29 In addition, severely
inflamed ducts may predispose the patient to greater perforation risk and/or persistent
bile leak. Following a cholangiogram with identification of the biliary tree, CBDE is
performed in a manner similar to the transcystic technique described earlier, but
with significant differences in opening and closure of the duct.

1. Administer 1 mg of IV glucagon before the start of exploration.

2. The CBD is exposed by carefully dissecting the peritoneum overlying the porta
hepatis.
3. Confirmation of the CBD can be achieved by either aspiration of bile with a fine-
gauge needle, or with laparoscopic ultrasonography. The latter can also be of
benefit by displaying CBD stones.
4. Using cold scissors an anterior longitudinal choledochotomy approximately 10 to
15 mm in length, or as big as the largest stone, is made. Care should be taken to
avoid injury to the vascular supply of the CBD, which parallels the duct at the 3 and
9 o’clock positions, because subsequent vascular injury may lead to increased
risk of stenosis and bile leak. Also, the ductotomy should be made as distal on
the CBD as possible in order to preserve as much duct as possible in case a
biliary-enteric anastomosis is necessary.
5. Although optional, stay sutures placed at both sides of the ductotomy using 4-0 or
5-0 PDS may assist in duct exposure and allow easier passage of catheters,
baskets, stones, and so forth.
6. A catheter is then placed into the ductotomy through one of the laparoscopic
ports that is most in line with the duct, typically one of the lateral ports. Although
several CBDE catheters exist, some investigators advocate using a 14-Fr red rub-
ber catheter, because this provides a semiflexible route for wire exchange and
higher-pressure irrigation.28
7. The duct is then thoroughly flushed with hand-pressurized injections of saline
because this may clear the duct. A follow-up cholangiogram can confirm the suc-
cess of this maneuver.
8. If stones are still present, CBDE exploration is then performed as described earlier
for the transcystic technique (steps 4 to 13).
9. If T-tube closure is chosen, the choledochotomy is then closed over a 10-Fr to
14-Fr T tube with the distal top portion of the T cut off to allow improved drainage
around and through the tube, as well as to make it more pliable for ease of
removal. The T tube can be gently pushed against the anteductomy side (intralu-
minally) while suturing the choledochotomy to avoid catching the tube with a su-
ture. Running or interrupted resorbable sutures (eg, 4-0 or 5-0 PDS) are then
placed proximal and distal to the tube; resorbable sutures are necessary to
reduce stone formation at the suture sites. The T tube is then pulled back against
the repair site while tying the final sutures close to the tube.
10. The T tube should be flushed with saline to assess for leakage around the tube,
brought out through one of the lateral trocars, and secured to the skin. Care
should be taken to position the tube intra-abdominally, allowing enough slack
to avoid tension being placed at the CBD insertion site.
 Bile Duct Evaluation and Exploration 291

11. Before desufflation and trocar removal an optional drain is placed near the chol-
edochotomy site and T tube in case of bile leakage around the tube during the
immediate postoperative period.
12. A completion cholangiogram is then performed through the T tube, with docu-
mentation of ductal clearance.
Although once considered routine, placement of a T tube is now performed more
selectively. Studies show comparable outcomes between routine and selective
T-tube placement, but with longer operative times and length of stay when a T tube
is placed.30,31 Others show more complications with T-tube placement including bile
leak and tube malfunction (slippage, entrapment).32 However, we routinely close our
defects over a T tube in order to adequately decompress the biliary system and provide
access for further imaging. In addition, clinical staff members taking care of the patient
on the ward should be educated as to proper T-tube care and maintenance. Staff mem-
bers need to minimize exterior tension on the tube to ensure there is no pulling of the
tube or accidental dislodgement. The tube should be flushed with sterile saline 2 to
3 times daily and placed to a gravity drainage bag for monitoring outputs.
If the surgeon is inexperienced in LCBDE and if an advanced endoscopist is avail-
able, an intraoperative ERCP with or without rendezvous procedure can be performed
in which a guidewire is placed transcystically or transcholedochally through the
papilla; the endoscope can grasp the guidewire for easier access to the biliary tree.
Transcholedochal or other types of rendezvous procedures such as percutaneous
and endoscopic ultrasonography–based wire placements aid in selective cannulation
of the papilla, thus improving stone clearance rates when difficult anatomy is encoun-
tered. As an alternative, a postoperative ERCP can be performed after placing a drain
near the cystic dump stump before closure. Because of increased intraluminal pres-
sures from contrast injections and ductal manipulations, we advocate cystic stump
closure using an endoloop for a more secure ligation. The biggest caveat is that if post-
operative ERCP is unsuccessful, the patient has to return to the OR for an additional
operative procedure for stone extraction.

Open CBDE
Although infrequently performed in surgical training programs, open common duct
exploration still plays a role in ductal clearance of impacted stones. Patients already
undergoing open procedures via midline or Kocher incisions, or conversions from
laparoscopic to open procedures, undergo open CBDE (OCBDE), if warranted. In
addition, OCBDE is indicated if unsuccessful with complete ductal clearance using
any of the laparoscopic techniques, if the anatomy is distorted or too inflamed for
safe access, or if the surgeon’s experience is too limited to safely perform it laparos-
copically. The OCBDE procedure mirrors that of the laparoscopic technique previ-
ously described, with some modifications. The CBD is opened in a similar fashion
after aspirating bile to confirm biliary duct dissection. Again, the duct should be irri-
gated with saline to potentiate stone clearance; small stones may pass through the
papilla or may float retrograde out through the choledochotomy. Papillary dilation
with a balloon catheter should be attempted to allow efflux of larger stones. An
open procedure has the benefit of direct manipulation and handling of the duct and
catheters. The papilla can be identified using a combination of fluoroscopy and palpa-
tion of the catheter within the duodenum. Stone extraction and choledochoscopy
should proceed as with a laparoscopic approach. A T tube with suture closure is like-
wise recommended, followed by flushing and a completion cholangiogram to confirm
ductal clearance and show free flow of contrast.
292 Orenstein et al

Persistent biliary obstruction with impacted stones necessitates transduodenal

exploration or, if severe enough, a biliary bypass procedure. Sphincterotomy can be
performed open with a transduodenal approach, or endoscopically with an ERCP.
For transduodenal sphincterotomy the duodenum is Kocherized followed by a 2-cm
to 4-cm longitudinal incision on the anterior surface of the second portion of the duo-
denum. A catheter placed into the CBD from the choledochotomy helps identify the
papilla. Traction sutures into the duodenal walls can be placed to improve exposure
of the duodenal lumen and papilla.29 A sphincterotomy is then performed in the biliary
side of the papilla at 10 o’clock, opposite the pancreatic duct. The sphincterotomy
may have to be extended over the stone if it is still impacted. Some surgeons prefer
to mature the distal CBD mucosa with the duodenum using resorbable sutures to
allow easier flow of stones and debris.29 Following stone extraction and T-tube place-
ment, the system should be flushed to clear debris and evaluate for leak at the sphinc-
terotomy site or choledochotomy and a cholangiogram performed to confirm ductal
clearance. The duodenotomy is then closed in 2 layers in a transverse manner. Before
abdominal closure, 1 or 2 drains should be placed around the duodenotomy and chol-
edochotomy until after adequate per oral intake, to rule out a duodenal or biliary leak.
For severely dilated CBD (2 cm) or impacted stones not amenable to other extraction
means, a biliary-enteric bypass procedure may be necessary, with either a choledo-
choduodenostomy or choledochojejunostomy.33

Intraoperative ERCP
Having an advanced endoscopist available to assist with ductal clearance in the oper-
ating room can be beneficial in the setting of preoperative liver function test (LFT) in-
crease (ie, planned intraoperative ERCP), intraoperative discovery of ductal filling
defects on cholangiogram, or inability to successfully clear the duct with CBDE. The
principal advantages of intraoperative ERCP include a single, albeit longer, anesthetic
exposure, the ability to identify complications from CBDE, and the ability to evaluate
altered papillary anatomy intraluminally. The use of a rendezvous procedure may aid
the endoscopist in accessing the papilla by placing a transcystic or transcholedochal
guidewire through the papilla into the duodenum for easier CBD access. An important
benefit of performing an ERCP intraoperatively is that, if the ERCP is unsuccessful, the
patient and surgical team are already in the operating room and a laparoscopic or open
CBDE can proceed without having the patient return for a subsequent procedure.
However, there are drawbacks to intraoperative ERCP beyond the logistical chal-
lenge of coordinating the surgeon and endoscopist schedules and managing resource
use of the procedure. Adding ERCP increases the operative time and anesthetic time,
especially for a difficult case. Difficulty might arise from the patient positioning,
because ERCPs are typically performed with the patient in a prone position. Although
supine-positioned ERCP is achievable it makes the procedure more challenging.
There are independent risks of ERCP that potentially add to the surgical risks,
including acute pancreatitis, bleeding, ascending biliary infection, and perforation.9–11
Insufflation can cause bowel dilatation, which may reduce abdominal domain and
operative working space. To compensate for this, clinicians may consider completing
or nearly completing the cholecystectomy before starting the ERCP. In addition, the
use of CO2 gas instead of air may help reduce bowel distention as well as reduce
postprocedure pain.34

Postoperative ERCP
There are several scenarios in which postoperative ERCP is warranted, including an
unsuccessful LCBDE. In this setting, a transcystic stent can be placed for temporary
 Bile Duct Evaluation and Exploration 293

biliary drainage, or a guidewire can be placed for easier endoscopic identification dur-
ing ERCP. In general, if an OCBDE has been embarked on, the operation should not be
terminated until stone clearance is complete and/or biliary drainage is achieved. If an
IOC is positive for ductal stones, bile duct exploration is not technically feasible, and
intraoperative ERCP is not available, the patient requires postoperative ERCP. It is
also possible for a stone to be incidentally introduced into the CBD from the gall-
bladder or cystic duct during cholecystectomy following a negative cholangiogram.
In addition, for an elderly or ill patient, ERCP may have to be deferred to a separate
postoperative period in order to decrease the anesthetic risks of a longer single oper-
ative procedure, although the patient would be exposed to 2 separate anesthetic
periods.

RESIDENT TRAINING IMPLICATIONS

There has been a significant paradigm shift over the last 2 decades with regard to resi-
dent and fellow training, because the advent of laparoscopy has shifted numerous
procedures from traditional open operations to minimally invasive techniques such
as laparoscopy or endoscopy. One of the most common situations in which this is
seen is in biliary procedures. Although multiple benefits of laparoscopy are
evident,35–38 the risk of CBD injury remain higher for laparoscopic (0.2%–0.5%) versus
open (0.2%)39,40 cholecystectomy. This rate of CBD injury during laparoscopy has pla-
teaued since resident and fellow trainees have become accustomed to the standard
technique of hepatobiliary triangle dissection and obtaining a critical view in order
to minimize CBD injury. In an effort to minimize and reduce CBD injury, Berci and col-
leagues41 advocate not only standardization of biliary dissection for all practitioners
but also intensive education of biliary surgical techniques for trainees. The investiga-
tors advocate specific educational components for cholangiography, simulation
training, didactics, and routine use of cholangiography in order to gain an exacting
description of biliary anatomy to minimize CBD injury.
The challenge of educating surgical trainees is to provide them with the funda-
mental knowledge to practice as general surgeons, despite a significant reduction
in exposure to open biliary procedures and CBDE. This reduction has led to a
growing trend of reliance on subspecialists and referrals to hepatobiliary-trained sur-
geons for management of what used to be in the realm of the general surgeon.42,43
The number of open biliary operations has been greatly reduced over the last 2 de-
cades, which has, in turn, led to reduced exposure to open procedures for
trainees.42 According to recent national case logs from the Accreditation Council
for Graduate Medical Education (ACGME), the average surgical resident graduates
with experience of only 10 open cholecystectomies performed compared with
more than 100 laparoscopic cholecystectomies.4 For CBDE, the average chief resi-
dent graduates having performed only 1 open and 1 laparoscopic CBDE, although
this has not significantly changed over the last decade, with only 2.5 open and 1 lapa-
roscopic CBDE reported on average from 1999 to 2002.4 Residents’ exposure to
open and CBD procedures is too limited to make a graduate proficient at such pro-
cedures. Thus, further discussion and debate are necessary to determine effective
and efficient methods for training residents and fellows for open and laparoscopic
common duct explorations.

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