الفهرس 
Anatomy of the Extrahepatic Biliary SystemOnly 14 pages are availabe for public view
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Abstract
C
ommon bile duct stones continue to pose a significant problem both to the patient and the surgeon. They increase the morbidity of a patient undergoing cholecystectomy. The incidence of common bile duct stones in patients having gallstones varies between 8 and 20 %. The incidence of common bile duct stones among patients undergoing cholecystectomy is 10% and the incidence of common bile duct stones unsuspected on preoperative investigations but discovered at the time of routine intra-operative cholangiography is from 3% to 5%.
One of the main reasons of investigating a patient with gallstones prior to cholecystectomy is to exclude the presence of associated CBD stones. All investigations are aimed at evolving a minimally invasive approach with the least number of complications achieved in a cost effectiveness manner to achieve a low overall morbidity of treatment. CBD stones are suspected if there is a history of pancreatitis or cholangitis, or there are increased serum levels of conjugated bilirubin, SGPT, SGOT and alk. phosph., or if there is dilatation of CBD more than 8mm or stone in the CBD at abdominal sonography or the presence of stones in the CBD at MRCP.
The treatment of common bile duct stones has shown considerable evolution over the last 4 decades. The cause for this evolution has been constant upgrading of technological capability, which allows treating clinicians to offer cure with the benefits of laparoscopic common bile duct exploration as, minimal discomfort, minimally invasion, wound related morbidity is avoided, single hospital admission, shorter hospital stay, quicker recovery, decreased morbidity and mortality and also avoid complications of ERCP as ERCP is an invasive procedure that has a complication rate of approximately 5-10% of cases. The most common complication is pancreatitis. Cholangitis, haemorrhage and duodenal perforation are the next most common complications.
Laparoscopic CBD exploration may be done after initial confirmation (detection) of a stone by IOC or 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.