*Laparoscopic Approach in the Case of Biliary Obstruction: Choledocholithiasis DOI: http://dx.doi.org/10.5772/intechopen.106042*

CBD diameters of 6 mm and 7 mm, respectively (as measured by operative cholangiogram) for proceeding with choledochotomy.

The cystic approach is possible even for the diameter of cystic duct of 3 mm. In this case, we try in advance to dilate the cystic duct by the balloon catheter and apply a 3 mm choledochoscope through it (3 mm choledochoscope, Karl Storz).

Before longitudinal incision on the CBD (**Figure 2**) we place two stay sutures (at 3 o'clock and 9 o'clock) (**Figure 3**). This can help visualization and improve one's ability to properly direct the incision. When the diameter of the cystic duct is too small, we perform a microincision at the cystic duct-CBD confluence.

Regarding the stone extraction from the bile duct, we usually apply a Dormia basket (**Figure 4**), a balloon catheter or blunt forceps. After complete removal of

**Figure 1.** *Dilated CBD >10 mm.*

**Figure 2.** *Longitudinal incision on the CBD.*

**Figure 3.** *Placement of 3 and 9 o'clock stay sutures on CBD.*

#### **Figure 4.**

*Applying Dormia basket for stones extraction.*

the stones, multiple lavages of CBD in both directions by Nelaton tube and Fogarty catheter size 4–5-F should be done until the clear fluid was obtained. After the complete clearance of proximal and distal parts of CBD (**Figures 5** and **6**), the patency is confirmed by choledochoscopy or intraoperative cholangiography.

Once all the stones are removed from the CBD (**Figures 7** and **8**), the incision of the bile duct should be closed over a T-tube or without it, with an interrupted 3/0 or 40 vicryl suture depending on the thickness of its wall (**Figure 9**).

*Laparoscopic Approach in the Case of Biliary Obstruction: Choledocholithiasis DOI: http://dx.doi.org/10.5772/intechopen.106042*

**Figure 5.** *Proximal lavage of CBD by Nelaton tube.*

#### **Figure 6.** *Distal lavage of CBD by Nelaton tube.*

Many authors do not advocate the usage of T-tube after choledochotomy, because of the risk of postoperative infectious complications. Although a 12–14-Fr T-tube is indicated after choledochotomy, in the cases of excessive manipulation and trauma of CBD, extraction of more than five CBD stones or suspicion of residual stones.

After the closure of the cystic duct or CBD, retrograde cholecystectomy should be finished, and the gallbladder is removed with a specimen retrieval bag.

**Figure 7.** *Gallstone into the CBD.*

**Figure 8.** *Extraction of gallstone from the CBD.*

A 16-Fr drain was placed in the subhepatic region after thorough saline lavage of this region to exclude bile leakage in the postoperative period.

*Laparoscopic Approach in the Case of Biliary Obstruction: Choledocholithiasis DOI: http://dx.doi.org/10.5772/intechopen.106042*

**Figure 9.** *T-tube into the CBD with sutures placed around.*
