This operation is less commonly indicated because of the widespread availability of ERCP. It is performed when ERCP fails or, when intra-operative cholangiography confirms bile duct stones. It is almost always an adjunct to cholecystectomy & the approach & closure are the same.

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Preoperative Preparation

• In obstructive jaundice, correct any clotting defects, give Vitamin K & maintain a diuresis with mannitol.
• Cover with prophylactic antibiotics

Procedure

• After the gallbladder has been removed, 'Kocherise' the duodenum (mobilise the second part.)
• Next, open the peritoneum to expose the CBD above the first part of the duodenum.
• Place two stay sutures at the level of the mid-portion of the CBD.
• Using a pointed scalpel and a Pott's right-angled scissors open the CBD vertically & extend the incision for about 2cm. Bile, and maybe stones, will spill out through the opening.
• From below, with fingers behind the duodenum & head of the pancreas, milk the CBD & retrieve stones as they emerge from the choledochotomy.
• Stones in the CBD can be extracted using Desjardins forceps or a Fogarty balloon catheter.
• A flexible choledochoscope allows visualisation of the common hepatic duct & its major branches proximally, & the CBD to the sphincter distally, to confirm duct clearance.
• When clear, insert a 14F Latex rubber T-tube (to promote a foreign body reaction) into the CBD & close the choledochotomy above the T-tube with interrupted absorbable sutures.

Bring the T-tube to the skin surface through a stab wound via the most direct route. Secure it carefully to the skin with stitch ligature & avoid kinks.

Postoperative Management

Perform a T-tube cholangiogram after one week. If this is clear, then clamp the T-tube. If no pain or jaundice occurs, remove it, but not before the 10th day, when a good tract will have formed.

Main Postoperative Complications

Retained stones or stones in the CBD.

Laparoscopic Exploration of the Common Bile Duct

• Can be performed as an extension of laparoscopic cholecystectomy.
• The CBD is explored either via the cystic duct, or directly into the CBD in a similar manner to that descrived above, using flexible cholecochoscopy and/or an x-ray image intensifier.