**7. Operative management of cholodocholithiasis**

## **7.1 Minimally invasive surgery**

## *7.1.1 Laparoscopic common bile duct exploration*

## *7.1.1.1 Transcystic duct procedure*

Trans-cystic duct procedure offers a good minimally invasive approach to CBD stones. This technique can effectively avoid a choledochotomy, resulting in the complexity of intracorporeal suture closure of the CBD. In the case of multiple stones, stone proximal to the cystic duct to bile duct junction, and fragile cystic duct, this technique is not preferable. Most trans-cystic duct procedure for CBD exploration require balloon dilatation of the cystic duct. Flexible biliary endoscopy with wired basket retrieval of calculi to be the safe technique due to direct vision of wired basket manipulation and stone capture [21].

The patient positioned and ports are set in the supine position similar to laparoscopic cholecystectomy. Guidewire is placed and positioned in cystic duct in preparation for advancing a balloon dilatation catheter for cystic duct dilatation. The balloon and cystic duct are observed laparoscopically for inflation of the balloon to the insufflation pressure recommended by the manufacturer. The cystic duct should never be dilated larger than the inner diameter of the CBD. Endoscopy can be inserted over a hydrophobic guidewire gently guided with an atraumatic grasper. After the endoscopy reaches in the cystic duct and the stone is seen and surrounded by the basket, it is gently closed and the stone and scope are withdrawn together [22]. The procedure is repeated until the duct is clear. After the completion of these processes, the cystic duct stump should be closed with a clip or a loop ligature.

### *7.1.1.2 Choledochotomy procedure*

Choledochotomy technique is preferable in the case of a dilated CBD greater than 10 mm, calculi 10 mm or larger, multiple calculi, impacted stone, or stones proximal to the cystic duct to bile duct junction. It is contraindication in a not dilated CBD because of increase difficulty and the risk of stricture. The advantages of choledochotomy are the calculi can easily be irrigated out of the CBD and an endoscopy can be inserted bidirectionally distal and proximal to bile duct. The disadvantages of choledochotomy are considerable laparoscopic suturing technique needed to close the choledochotomy wound.

The anterior wall of the CBD is dissected sharply and bluntly caring for the multiple small vessels in the area. The choledochotomy should be created in the CBD below the cystic duct and the CBD junction. Two stay sutures are placed in the CBD area, which tent the anterior wall and prevent injury to the posterior wall on incising the CBD longitudinally. The length of choledochotomy should be the same as the circumference of the largest calculi to minimize the suturing needed for closure. Introduction of the choledochoscope is done through a subcostal trocar and inserted through the choledochotomy into the CBD. A biliary wire basket or balloon catheter is used to capture and remove calculi. After finishing complete clearance

of the CBD, it is possible to close the choledochotomy wound. However, concerning about large number of stones, recurrent stones, or remnant stones, surgical drainage of the CBD is needed. Surgical drainage includes T-tube drainage, choledochoduodenostomy, or choledocho-jejunostomy.
