الفهرس 
Surgical Anatomy of the GallbladderOnly 14 pages are availabe for public view
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Abstract
Summary
Choledocholithiasis is a common problem that usually
necessitates surgical intervention.
CBD stones are suspected if there is a history of
pancreatitis or cholangitis, or there is an increased serum level
of conjugated bilirubin, SGPT, SGOT and alk. phosph., and
diagnosis is confirmed if there is dilatation of CBD more than
8mm or stone in the CBD at abdominal ultra-sonography or
the presence of stone in the CBD at MRCP.
Many different strategies are available for the management
of CBD stones:
• Open surgical cholecystectomy and common bile duct
exploration (CBDE) and stone extraction.
• (LC), preoperative (ERCP) plus sphincterotomy followed
by LC replaced open surgery due to less postoperative pain,
hospital stay, return to work, and cosmoses.
• However, ERCP has issues, such as failure rate as high as
10% to 25%.and procedure-related complications,
including bleeding, perforation and pancreatitis. Also,
ERCP plus sphincterotomy lead to the disruption of the
intact sphincter of Oddi Failure.
• LCBDE: trans-cystic (via the cystic duct) and trans-ductal
(via choledochotomy)
Summary
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Trans-cystic approach is generally used for small stones in
a small bile duct whereas trans-ductal approach is preferred for
large occluding stones in a large duct, intra-hepatic stones or
tortuous cystic ductIf CBDS are detected at the time of
laparoscopic cholecystectomy, the best treatment is a trans-cystic
laparoscopic approach during the same operation, If this fails,
alternate approaches such as intra-operative or postoperative
ERCP/EST, laparoscopic choledochotomy, or open CBDE may
be used .
The successful laparoscopic management of CBD stones
depends on several factors including:
- Surgical expertise which may be enhanced by Training
models in laparoscopic surgery.
- Adequate equipment (Flexible choledocho-fiberscope,
balloon catheter, basket forceps or IOC).
- The biliary anatomy, and the number and size of CBD
stones.
A closed non suction drain should be placed at the site of
closure. This may drain bile for a day or two prospectively, but
inevitably dries up quickly provided the closure has been carefully
performed.