Laparoscopic trans-cystic common bile duct stone retrieval i
A 69-year-old man presented to the emergency department with three days of right upper quadrant and epigastric pain, jaundice and nausea. He had no previous abdominal surgeries.

On examination he was found to be jaundiced, with right upper quadrant tenderness. He had a negative Murphy’s sign. Liver function tests demonstrated a bilirubin of 154 umol/L, with an alanine transaminase of 732 U/L, aspartate transaminase of 448 U/L, alkaline phosphatase of 244 U/L and gamma-glutamyl transferase of 636 U/L. He was placed on intravenous ceftriaxone and metronidazole while awaiting imaging.

Transabdominal ultrasound of the biliary tract was limited by bowel gas but reported an impression of multiple stones in the region of the gallbladder. The CBD was measured at 7 mm but was not entirely visualized and intrahepatic ducts were dilated up to 5 mm.

The patient then proceeded to have a magnetic resonance cholangiopancreatography (MRCP) scan for further assessment of the biliary tree. This demonstrated choledocholithiasis within the distal CBD measuring 5.9 mm. The gallbladder was reported as only seen on axial T2 weighted images. The impression was the patient may have chronic cholecystitis with a shrunken gallbladder. Given the experience of the hepatobiliary surgeon involved in the case, a decision was made to proceed to laparoscopic cholecystectomy.

On laparoscopy, the gallbladder could not be identified on exploration of the liver bed. The principle of safe dissection, above axis of the sulcus of Rouviere, was followed to identify landmarks. MRCP imaging was reviewed again intra-operatively to help guide the surgical team and avoid commencing the dissection too low, given that a gallbladder was not present in the fossa. A 2 cm cystic duct stump and cystic artery was identified. An intra-operative cholangiogram was performed, confirming a distal CBD filling defect (Fig. 3). CBD clearance under direct vision with choledochoscopy was performed to extract a 7 mm stone. The cystic duct was then secured with two PDS Endoloop® Ligatures and sent for histology. A drain tube was placed along the liver bed.

The patient was discharged home Day 5 post-operatively following removal of his drain tube. He was reviewed in the general surgery outpatient clinic 2 weeks following discharge where he had made a good recovery. There were no symptoms or signs of post-operative complications and his pain had resolved. His bilirubin and liver function tests had returned to normal. He was subsequently discharged from clinic following this review.

Source: Journal of Surgical Case Reports, Volume 2019, Issue 3, March 2019, rjz094

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