الفهرس 
EmbryologyOnly 14 pages are availabe for public view
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Abstract
The incidence of common bile duct stones in patients having gallstones varies between 8 and 20 percent.10-30% of gall stones will become symptomatic.
Common bile duct stones are usually accompanied by gallbladder stones but in about 5% of cases the gallbladder is empty.
Attacks of biliary colic and obstructive Jaundice is seen if a stone obstructs the Common bile duct.In the absence of infected bile,asymptomatic jaundice, often fluctuating, will ensue and in many patients there will be spontaneous complete resolution. This will happen if as ductal dilatation develops, the stone floats back up the Common bile duct and away from the narrow distal and as an edema subsides. However, occasionally jaundice is relieved because the stone indeed passes into the duodenum.
High values (more than or equal to the double of the normal value) of serum glutamic oxalacetic transminase (SGOT), Alkaline phosphatase (ALP) and conjugated bilirubin with dilated duct (>8mm) are all diagnostic factors of common bile duct lithiasis.
Abdominal ultrasound, endoscopic ultrasound, computerized tomography scan (CT scan), computerized tomography chalangioogram (CT chalangiogram), Magnetic resonance cholangiopancreatography, Endoscopic retrograde cholangiopancreatography (ERCP) Percutanous transhepatic cholangiography, all are radiological tools to detecte presence of common bile duct stones.
The modern era of common bile duct surgery started with Mirizzi, who introduced the intra-operative cholangiography in 1932. Intra-operative choledochoscopy had been developed as an adjunctive to intra-operative cholangiography, which helped to detect the common bile duct stones in an additional 10% to 15% of instances that otherwise an important technique for efficient and effective management of common bile duct stones. Efforts have been exerted to treat patients with common bile duct stones in one session and avoid potential complications of endoscopic sphincterotomy.
Laparoscopic bile duct clearance, which was first carried out in April 1990, has since then been shown to be potentially preferable option when compared with endoscopic retrograde cholangio-pancreatography (ERCP), allowing the surgeon to reclaim the treatment of common bile duct stones detected at routine intra-operative cholangiography.
Recently, single stage laparoscopic cholecystectomy and laproscopic exploration of common bile duct is the primary apporach for patients with common bile duct stones, except in the presence of severe biliary sepsis.
When one considers the costs, morbidity, mortality and the time required before the patient can return to work, it would appear that laparoscopic cholecystectomy with common bile duct exploration is more favorable than open surgery or laparoscopic cholecystectomy with pre-operative or postoperative endoscopic sphincterotomy. However the technique requires advanced laparoscopic skills, including suturing, and the use of a choledochoscope, guidewires, dilators and balloon stone extractor; it should be emphasized that this procedure is very challenging, and it should be performed by well-trained laparoscopic surgeons with experience in biliary surgery.
Although laparoscopic common bile duct exploration appears to be the most cost-effective method to treat common bile duct stones. Occasionally, anatomic or physiologic considerations preclude the minimal access approach, and conversion to an open operation in such cases reflects sound judgment and should not be considered a complication.
Laparoscopic CBD exploration may be done after initial confirmation (detection) of a stone by IOC laparoscopic ultrasound. The cystic duct is dilated with graded dilators, balloon dilatation and Choledochoscopic stone removal is done. The same limitations to transcystic intervention are applicable in laparoscopy as well. Alternatively the CBD may be approached by a choledo-chotomy where the CBD is opened with scissors or a harmonic scalpel and the CBD explored using a therapeutic choledochoscope. Alternatively Steerable catheters under fluoroscopic guidance are used. Laparoscopic ante grade sphincterotomy may be added to provide bile duct drainage and to prevent the problem of recurrence.