Dr Sameer Mihrshahi

This procedure may be needed if gallstones are found in the common bile duct (CBD), either on pre-operative imaging (ultrasound, specialised CT scan or MRI) or after the cholangiogram has been performed during a laparoscopic cholecystectomy.

The ways to explore the bile duct depend on a number of factors, including the local anatomy (size and length of the cystic duct, how it joins the common bile duct, the size of the bile duct, and the size and location of the gallstones, and the available equipment at a particular hospital). The commonest way to extract the stones is through the opening made in the cystic duct for the cholangiogram (this is known as a transcystic common bile duct exploration) - the other way is by opening the common bile duct directly (called a choledochotomy) and once the stones have been removed, closing this with sutures.

With a transcystic common bile duct exploration, at Macquarie University Hospital I prefer to use a choledochoscope which is a very small (2.8mm) flexible telescope which is directed through the opening in the cystic duct and into the common bile duct. This is able to give a direct view of the inside of the bile duct, and a basket can be placed through this to remove the stones under vision, as well as to make sure the duct is clear at the end of the procedure.

The first image shows the flexible choledochoscope in position in the cystic duct. The second shows the stone extracted using a basket passed down the choledochoscope, and the third shows a view of the lower part of the CBD through the choledochoscope.

At Ryde and Mona Vale Hospitals, we don't have access to a choledochoscope, so we tend to use a special basket that is placed down the bile duct under X-ray control to try and remove the stones.

On completion of a successful CBD exploration, the gallbladder operation is completed as usual, with the exception that I will usually place a drain (a soft plastic tube) through one of the 5mm laparoscopic ports with it's tip where the clips/sutures are on the duct so that we can make sure there is no evidence of bile leak the following day. As long as there is no bile in the drain, it is removed 1-2 days after the surgery.

If we are unable to remove the stones from the CBD, I place a plastic tube called a stent across the muscle at the lower end of the bile duct, to prevent the stone(s) from getting stuck and causing problems. We then need to organise another procedure, called an ERCP, which is a procedure done via a flexible telescope put through the mouth that removes the stones that way - this can be done 2-3 weeks after the surgery as long as you are recovering fine.