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Transhepatic percutaneous biliary tract drainage
Percutaneous transhepatic biliary drainage is an effective method for the primary or palliative treatment of many biliary strictures. It is a procedure which includes the cannulation of an intrahepatic biliary tree using image-guided wire and catheter manipulation, and placement of a tube or stent for external and/or internal drainage. This video shows this technique applied in a patient with a pancreatic tumor.
This is the case of an 80-year-old male patient with signs of jaundice and a diagnosis of intrahepatic and extrahepatic bile duct dilatation and pancreatic tumor.
A transhepatic percutaneous biliary tract drainage was the therapeutic strategy.
F Davrieux, ME Gimenez, EJ Houghton, M Palermo, D Mutter, J Marescaux
Surgical intervention
1 year ago
3640 views
593 likes
0 comments
20:25
Transhepatic percutaneous biliary tract drainage
Percutaneous transhepatic biliary drainage is an effective method for the primary or palliative treatment of many biliary strictures. It is a procedure which includes the cannulation of an intrahepatic biliary tree using image-guided wire and catheter manipulation, and placement of a tube or stent for external and/or internal drainage. This video shows this technique applied in a patient with a pancreatic tumor.
This is the case of an 80-year-old male patient with signs of jaundice and a diagnosis of intrahepatic and extrahepatic bile duct dilatation and pancreatic tumor.
A transhepatic percutaneous biliary tract drainage was the therapeutic strategy.
Laparoscopic Beger procedure with Roux-en-Y hepaticojejunostomy
This is the case of a 49-year-old male patient presenting with recurrent intractable abdominal pain. The patient had a history of obstructive jaundice and underwent biliary decompression provided by a percutaneous cholecystostomy. CT-scan showed signs of chronic pancreatitis, multiple stones in the pancreatic parenchyma, a compressed portal vein and biliary obstruction. The patient underwent a laparoscopic duodenum-preserving pancreatic head resection (DPPHR) – a technique known as the Beger procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain, combined with portal and biliary compression caused by severe chronic pancreatitis. The surgical procedure preserves the stomach, the duodenum, and the biliary tree unlike standard duodenopancreatectomy (Whipple procedure), which is the other option for these patients. As Beger himself stated: “Preservation of the duodenum and the biliary system has major advantages for patients regarding short- and long-term outcome as compared to the Kausch-Whipple resection and pylorus-preserving resection”.
In this case, after completing the pancreatic head resection and fashioning the distal and proximal pancreaticojejunal anastomosis, a hepaticojejunostomy was performed. It was necessary due to the stenosis of the intrapancreatic segment of the common bile duct.
The purpose of this video is to demonstrate that the laparoscopic Beger procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay.
P Agami, A Andrianov, M Baychorov, R Izrailov
Surgical intervention
1 month ago
648 views
7 likes
2 comments
17:23
Laparoscopic Beger procedure with Roux-en-Y hepaticojejunostomy
This is the case of a 49-year-old male patient presenting with recurrent intractable abdominal pain. The patient had a history of obstructive jaundice and underwent biliary decompression provided by a percutaneous cholecystostomy. CT-scan showed signs of chronic pancreatitis, multiple stones in the pancreatic parenchyma, a compressed portal vein and biliary obstruction. The patient underwent a laparoscopic duodenum-preserving pancreatic head resection (DPPHR) – a technique known as the Beger procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain, combined with portal and biliary compression caused by severe chronic pancreatitis. The surgical procedure preserves the stomach, the duodenum, and the biliary tree unlike standard duodenopancreatectomy (Whipple procedure), which is the other option for these patients. As Beger himself stated: “Preservation of the duodenum and the biliary system has major advantages for patients regarding short- and long-term outcome as compared to the Kausch-Whipple resection and pylorus-preserving resection”.
In this case, after completing the pancreatic head resection and fashioning the distal and proximal pancreaticojejunal anastomosis, a hepaticojejunostomy was performed. It was necessary due to the stenosis of the intrapancreatic segment of the common bile duct.
The purpose of this video is to demonstrate that the laparoscopic Beger procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay.
Minimal access surgery approach to benign biliary disease
The laparoscopic biliary approach for benign diseases has been discussed for a quarter of a century. However, there were few articles in the literature about laparoscopic bilioenteric anastomoses, such as choledochoduodenostomy and hepatico/choledochojejunostomy which require advanced laparoscopic skills and experience. In this key lecture, Dr. Asbun demonstrates his own laparoscopic techniques for bilioenteric anastomoses. For choledochal cysts representative of benign biliary diseases, cyst excision is required. The difficulty lies in the fact that the cyst extends towards the intrapancreatic portion. Dr. Asbun demonstrates the techniques for complete exposure of the intrapancreatic bile duct portion in such cases. Finally, Dr. Asbun shows bile duct injury cases managed using a hepaticojejunostomy.
HJ Asbun
Lecture
5 months ago
796 views
6 likes
2 comments
24:34
Minimal access surgery approach to benign biliary disease
The laparoscopic biliary approach for benign diseases has been discussed for a quarter of a century. However, there were few articles in the literature about laparoscopic bilioenteric anastomoses, such as choledochoduodenostomy and hepatico/choledochojejunostomy which require advanced laparoscopic skills and experience. In this key lecture, Dr. Asbun demonstrates his own laparoscopic techniques for bilioenteric anastomoses. For choledochal cysts representative of benign biliary diseases, cyst excision is required. The difficulty lies in the fact that the cyst extends towards the intrapancreatic portion. Dr. Asbun demonstrates the techniques for complete exposure of the intrapancreatic bile duct portion in such cases. Finally, Dr. Asbun shows bile duct injury cases managed using a hepaticojejunostomy.
Laparoscopic cholecystectomy - Basic rules - Bile duct injury
There is twice as much risk of incidental biliary injuries in laparoscopic cholecystectomy than in open cholecystectomy.
About half of surgeons will cause a bile duct injury during their careers. In this lecture, Dr. Dallemagne provides key national data of bile duct injury and explains that the lack of surgical experience or visual misperception leads to an increase in the rate of incidental injuries, mentioning his own cases. Dr. Dallemagne also outlines the fundamental techniques to prevent injuries and use bailout procedures (partial and subtotal cholecystectomy) in laparoscopic cholecystectomy, according to the latest version of the Tokyo guidelines.
B Dallemagne
Lecture
5 months ago
4043 views
37 likes
2 comments
22:02
Laparoscopic cholecystectomy - Basic rules - Bile duct injury
There is twice as much risk of incidental biliary injuries in laparoscopic cholecystectomy than in open cholecystectomy.
About half of surgeons will cause a bile duct injury during their careers. In this lecture, Dr. Dallemagne provides key national data of bile duct injury and explains that the lack of surgical experience or visual misperception leads to an increase in the rate of incidental injuries, mentioning his own cases. Dr. Dallemagne also outlines the fundamental techniques to prevent injuries and use bailout procedures (partial and subtotal cholecystectomy) in laparoscopic cholecystectomy, according to the latest version of the Tokyo guidelines.
Laparoscopic common bile duct exploration using a disposable fiber-optic bonchoscope (Ambu® aScope™)
Background: Laparoscopic common bile duct (CBD) exploration can be performed following choledochotomy or via the trancystic approach. Laparoscopic CBD exploration is limited in some benign upper gastrointestinal units due to the cost of sterilization of the reusable choledochoscope.
We have recently published a case series confirming the safety and efficacy of the 5mm reusable bronchoscope for CBD exploration. This case series evaluates a single-use bronchochoscope (Ambu® aScope™) for laparoscopic CBD exploration.
Method: A retrospective study was conducted from January 2015 to December 2016. Data was collected from electronic records of the patients. All cases confirmed the presence of CBD stones using USS and MRCP. The disposable bronchoscope is introduced via an epigastric port. Choledochotomy is performed using a choledochotome, and a transcystic approach is used after cystic duct dilatation, if required. The Ambu® aScope™ 2 (Ambu UK Ltd, Cambridgeshire) is a sterile and single-use flexible bronchoscope, which is normally used by anesthesiologists for difficult tracheal intubation. A disposable bronchoscope is available in two sizes (3.8mm and 5mm). It is a one-piece unit with a single dimensional flexible tip manipulated with a handpiece (150-degree flex in the 5mm model and 130-degree flex in the 3.8mm model). There is a single instrument channel with a 2.2mm diameter, which allows for the passage of standard endoscopic baskets for CBD stone retrieval. The image is projected to a high-resolution 6.5” LCD screen with a resolution of 640x480 pixels. The bronchoscope handpiece includes a suction port, which is used as an irrigation source for CBD dilatation. It requires the use of a standard 3-way connector.
Results: Twenty nine patients had CBD exploration using the disposable bronchochoscope. There were 10 male and 19 female patients (median age: 42). Ten procedures were performed as emergencies and 19 were performed electively. All cases were managed laparoscopically except one, which was planned as an open procedure due to previous extensive open surgery.
Twenty eight patients had their CBD cleared using a disposable bronchoscope and two needed subsequent ERCP. Choledochotomy was performed in 15 patients and a transcystic approach was used in 6 patients. No T-tube was used in the laparoscopic cases. Two cases were performed as day case surgery. Median postoperative hospital stay was 2.5 days.
Conclusion: The disposable bronchoscope is a safe and effective instrument for CBD exploration, with results comparable to our previously published case series. It has guaranteed sterility and is cost-effective compared to the reusable bronchoscope, especially when initial capital outlay, sterile processing and maintenance costs are considered.
Y Aawsaj, I Ibrahim, A Mitchell, A Gilliam
Surgical intervention
1 month ago
295 views
6 likes
1 comment
10:08
Laparoscopic common bile duct exploration using a disposable fiber-optic bonchoscope (Ambu® aScope™)
Background: Laparoscopic common bile duct (CBD) exploration can be performed following choledochotomy or via the trancystic approach. Laparoscopic CBD exploration is limited in some benign upper gastrointestinal units due to the cost of sterilization of the reusable choledochoscope.
We have recently published a case series confirming the safety and efficacy of the 5mm reusable bronchoscope for CBD exploration. This case series evaluates a single-use bronchochoscope (Ambu® aScope™) for laparoscopic CBD exploration.
Method: A retrospective study was conducted from January 2015 to December 2016. Data was collected from electronic records of the patients. All cases confirmed the presence of CBD stones using USS and MRCP. The disposable bronchoscope is introduced via an epigastric port. Choledochotomy is performed using a choledochotome, and a transcystic approach is used after cystic duct dilatation, if required. The Ambu® aScope™ 2 (Ambu UK Ltd, Cambridgeshire) is a sterile and single-use flexible bronchoscope, which is normally used by anesthesiologists for difficult tracheal intubation. A disposable bronchoscope is available in two sizes (3.8mm and 5mm). It is a one-piece unit with a single dimensional flexible tip manipulated with a handpiece (150-degree flex in the 5mm model and 130-degree flex in the 3.8mm model). There is a single instrument channel with a 2.2mm diameter, which allows for the passage of standard endoscopic baskets for CBD stone retrieval. The image is projected to a high-resolution 6.5” LCD screen with a resolution of 640x480 pixels. The bronchoscope handpiece includes a suction port, which is used as an irrigation source for CBD dilatation. It requires the use of a standard 3-way connector.
Results: Twenty nine patients had CBD exploration using the disposable bronchochoscope. There were 10 male and 19 female patients (median age: 42). Ten procedures were performed as emergencies and 19 were performed electively. All cases were managed laparoscopically except one, which was planned as an open procedure due to previous extensive open surgery.
Twenty eight patients had their CBD cleared using a disposable bronchoscope and two needed subsequent ERCP. Choledochotomy was performed in 15 patients and a transcystic approach was used in 6 patients. No T-tube was used in the laparoscopic cases. Two cases were performed as day case surgery. Median postoperative hospital stay was 2.5 days.
Conclusion: The disposable bronchoscope is a safe and effective instrument for CBD exploration, with results comparable to our previously published case series. It has guaranteed sterility and is cost-effective compared to the reusable bronchoscope, especially when initial capital outlay, sterile processing and maintenance costs are considered.
Bile duct injury: what to do?
In this key lecture, Dr. Soubrane outlines the various types of bile duct injuries and demonstrates how to manage them, classifying them into bile duct injuries during or after index surgery. When injuries are detected during index surgery, surgeons either have to add stitches combined with drainage in case of minor injuries or create an anastomosis in case of complete common bile duct division. When injuries are detected after index surgery, surgeons may either solve them with endoscopic stenting in case of minor injuries or have to wait at least 2 months in case of complete common bile duct division. As an example of major liver resection for severe bile duct injuries, Dr. Soubrane also shows a case of right liver resection for severe bile duct injury with concomitant arterial interruption and massive portal vein thrombosis after laparoscopic cholecystectomy.
O Soubrane
Lecture
5 months ago
1878 views
13 likes
1 comment
31:48
Bile duct injury: what to do?
In this key lecture, Dr. Soubrane outlines the various types of bile duct injuries and demonstrates how to manage them, classifying them into bile duct injuries during or after index surgery. When injuries are detected during index surgery, surgeons either have to add stitches combined with drainage in case of minor injuries or create an anastomosis in case of complete common bile duct division. When injuries are detected after index surgery, surgeons may either solve them with endoscopic stenting in case of minor injuries or have to wait at least 2 months in case of complete common bile duct division. As an example of major liver resection for severe bile duct injuries, Dr. Soubrane also shows a case of right liver resection for severe bile duct injury with concomitant arterial interruption and massive portal vein thrombosis after laparoscopic cholecystectomy.
Laparoscopic cholecystectomy: cystic duct stone management
This video demonstrates a laparoscopic cholecystectomy in a 69-year-old woman who had multiple episodes of biliary colic. Ultrasonography and MRI showed the presence of multiple gallbladder stones. MRI also showed a folded gallbladder infundibulum over the cystic duct, which is enlarged and contains a stone. The common bile duct is otherwise perfectly thin and free of stones. In this video, one can observe a stepwise cholecystectomy technique, with exposure, dissection of the serosa and of Calot’s triangle. Cystic artery division is first performed in order to allow complete cystic duct dissection obtaining the critical view of safety. The dissection of the dilated cystic duct is thoroughly demonstrated. A small stone is pushed back into the gallbladder; the cystic duct is opened and checked for residual stones, and the cystic duct convergence with the common bile duct is evidenced prior to clip positioning and duct division.
M Ignat, M Wehr, B Seeliger, D Mutter, J Marescaux
Surgical intervention
8 months ago
2987 views
11 likes
0 comments
10:44
Laparoscopic cholecystectomy: cystic duct stone management
This video demonstrates a laparoscopic cholecystectomy in a 69-year-old woman who had multiple episodes of biliary colic. Ultrasonography and MRI showed the presence of multiple gallbladder stones. MRI also showed a folded gallbladder infundibulum over the cystic duct, which is enlarged and contains a stone. The common bile duct is otherwise perfectly thin and free of stones. In this video, one can observe a stepwise cholecystectomy technique, with exposure, dissection of the serosa and of Calot’s triangle. Cystic artery division is first performed in order to allow complete cystic duct dissection obtaining the critical view of safety. The dissection of the dilated cystic duct is thoroughly demonstrated. A small stone is pushed back into the gallbladder; the cystic duct is opened and checked for residual stones, and the cystic duct convergence with the common bile duct is evidenced prior to clip positioning and duct division.
Laparoscopic cholecystectomy in a patient with nonalcoholic steatohepatitis (NASH) and idiopathic thrombocytopenic purpura
Morbid obesity surgery, which induces a rapid weight loss, is a predisposing factor for the onset of gallstones. There are treatments which help to reduce this risk. However, the observance is poor and lithogenicity brings about risks of complications such as cholecystitis, stone migration, and acute pancreatitis.
This video demonstrates the case of a patient who underwent a sleeve gastrectomy with a substantial weight loss. Stone migration was found along with a less serious pancreatic response. During a blood test analysis, thrombocytopenia was found and investigated by hematologists. Besides a low platelet count, a qualitative anomaly was observed increasing the risk of bleeding. Despite of this, cholecystectomy was necessary to prevent any new stone migration.
The operator was skilled and used a conventional laparoscopic approach. The patient’s liver is the site of a nonalcoholic steatohepatitis (NASH), making the procedure even more complex. Four ports were placed to allow for an adequate gallbladder retraction and for a minute dissection. Calot’s triangle was classically approached first as soon as the adhesions between the omentum and the gallbladder were taken down. Due to a thickened and inflammatory cystic duct, the entire gallbladder was dissected before ligating the cystic duct with two ligatures, one of them being reinforced by means of a surgical loop.
M Vix, B Seeliger, D Mutter, J Marescaux
Surgical intervention
8 months ago
830 views
2 likes
0 comments
13:25
Laparoscopic cholecystectomy in a patient with nonalcoholic steatohepatitis (NASH) and idiopathic thrombocytopenic purpura
Morbid obesity surgery, which induces a rapid weight loss, is a predisposing factor for the onset of gallstones. There are treatments which help to reduce this risk. However, the observance is poor and lithogenicity brings about risks of complications such as cholecystitis, stone migration, and acute pancreatitis.
This video demonstrates the case of a patient who underwent a sleeve gastrectomy with a substantial weight loss. Stone migration was found along with a less serious pancreatic response. During a blood test analysis, thrombocytopenia was found and investigated by hematologists. Besides a low platelet count, a qualitative anomaly was observed increasing the risk of bleeding. Despite of this, cholecystectomy was necessary to prevent any new stone migration.
The operator was skilled and used a conventional laparoscopic approach. The patient’s liver is the site of a nonalcoholic steatohepatitis (NASH), making the procedure even more complex. Four ports were placed to allow for an adequate gallbladder retraction and for a minute dissection. Calot’s triangle was classically approached first as soon as the adhesions between the omentum and the gallbladder were taken down. Due to a thickened and inflammatory cystic duct, the entire gallbladder was dissected before ligating the cystic duct with two ligatures, one of them being reinforced by means of a surgical loop.
Laparoscopic bile duct exploration with bile duct endoscopy and biliary bypass for recurrent biliary pancreatitis after cholecystectomy
This video shows the peculiar case of a 50-year-old male patient who underwent an open cholecystectomy for acute cholecystitis 12 years ago and he has been consulting for pancreatitis symptoms during the last seven years.
The patient reported that he had undergone ERCP twice after cholecystectomy because of bile duct stones and reportedly, complete bile duct clearance was achieved both times.
He presented to our facility with a new episode of mild pancreatitis.
No abnormalities were demonstrated in liver function tests. Amylase, GGT, and alkaline phosphatase values were normal.
Hepatobiliary ultrasound demonstrated a dilated common bile duct. MRCP (cholangio-MRI) showed several filling defects, particularly in the common bile duct and the left hepatic duct. CT-scan of the pancreas did not reveal abnormalities within the pancreatic parenchyma.
We decided to perform a bile duct exploration with endoscopic evaluation of the entire biliary tree and to perform a Roux-en-Y hepaticojejunostomy because of recurrent biliary pancreatitis after cholecystectomy.
JM Cabada-Lee
Surgical intervention
2 years ago
1932 views
106 likes
0 comments
10:55
Laparoscopic bile duct exploration with bile duct endoscopy and biliary bypass for recurrent biliary pancreatitis after cholecystectomy
This video shows the peculiar case of a 50-year-old male patient who underwent an open cholecystectomy for acute cholecystitis 12 years ago and he has been consulting for pancreatitis symptoms during the last seven years.
The patient reported that he had undergone ERCP twice after cholecystectomy because of bile duct stones and reportedly, complete bile duct clearance was achieved both times.
He presented to our facility with a new episode of mild pancreatitis.
No abnormalities were demonstrated in liver function tests. Amylase, GGT, and alkaline phosphatase values were normal.
Hepatobiliary ultrasound demonstrated a dilated common bile duct. MRCP (cholangio-MRI) showed several filling defects, particularly in the common bile duct and the left hepatic duct. CT-scan of the pancreas did not reveal abnormalities within the pancreatic parenchyma.
We decided to perform a bile duct exploration with endoscopic evaluation of the entire biliary tree and to perform a Roux-en-Y hepaticojejunostomy because of recurrent biliary pancreatitis after cholecystectomy.
Accidental finding of Ascaris lumbricoides in the common bile duct during laparoscopic cholecystectomy transcystic exploration
This is the case of a 37-year-old woman, who had acute cholecystitis for 4 days, accompanied by nausea, vomiting, and abdominal pain in the right upper quadrant.
Physical exam demonstrated a soft abdomen with right upper quadrant pain, positive Murphy’s sign, and a palpable painful mass.
Complete blood count (CBC) reported 7,700/uL WBC, 4.235u/L neutrophils (55%), 1.463u/L lymphocytes (19%), and 1.540/uL eosinophils (20%).
Total bilirubin: 0.7mg/dL, direct bilirubin: 0.4mg/dL, indirect bilirubin: 0.3mg/dL, alkaline phosphatase: 184U/L.
Hepatobiliary ultrasound reports a thin-walled bladder with biliary sludge. The bile duct is not dilated. According to the results, there was no parasite on the bile duct.
Pain does not subside with antispasmodics, and the patient is sent to undergo a laparoscopic cholecystectomy.
In surgery, a hydropic gallbladder was evidenced. It was drained with a Veress needle. It was then found that the cystic duct was dilated and a transcystic exploration was performed with a No. 6 - 8- 10 French gastric tube.
An Ascaris lumbricoides of 25cm in length was extracted.
After exploration was completed with a Fogarty catheter, and no additional parasites were found, conventional cholecystectomy was completed. Antibiotic and anti-parasite treatment was prescribed. The patient was discharged 2 days after the procedure without any complications.
LE Becerra
Surgical intervention
2 years ago
2044 views
126 likes
0 comments
08:19
Accidental finding of Ascaris lumbricoides in the common bile duct during laparoscopic cholecystectomy transcystic exploration
This is the case of a 37-year-old woman, who had acute cholecystitis for 4 days, accompanied by nausea, vomiting, and abdominal pain in the right upper quadrant.
Physical exam demonstrated a soft abdomen with right upper quadrant pain, positive Murphy’s sign, and a palpable painful mass.
Complete blood count (CBC) reported 7,700/uL WBC, 4.235u/L neutrophils (55%), 1.463u/L lymphocytes (19%), and 1.540/uL eosinophils (20%).
Total bilirubin: 0.7mg/dL, direct bilirubin: 0.4mg/dL, indirect bilirubin: 0.3mg/dL, alkaline phosphatase: 184U/L.
Hepatobiliary ultrasound reports a thin-walled bladder with biliary sludge. The bile duct is not dilated. According to the results, there was no parasite on the bile duct.
Pain does not subside with antispasmodics, and the patient is sent to undergo a laparoscopic cholecystectomy.
In surgery, a hydropic gallbladder was evidenced. It was drained with a Veress needle. It was then found that the cystic duct was dilated and a transcystic exploration was performed with a No. 6 - 8- 10 French gastric tube.
An Ascaris lumbricoides of 25cm in length was extracted.
After exploration was completed with a Fogarty catheter, and no additional parasites were found, conventional cholecystectomy was completed. Antibiotic and anti-parasite treatment was prescribed. The patient was discharged 2 days after the procedure without any complications.
Biliary access techniques in patients with surgically altered anatomy
Iatrogenic bile duct injuries following surgery are associated with life-threatening complications.
Most injuries occur following open or laparoscopic cholecystectomies. The incidence of bile duct injury (BDI) has increased when a laparoscopic approach is used.
The current incidence of BDI using a laparoscopic approach is comprised between 0.5 and 2.7%.
The presented clinical cases include bile leakage, bilioma, peritonitis or a local abscess, and only 30% of cases are recognized intraoperatively.
The main modality of treatment is surgery. However, endoscopic management is a current alternative.
This video highlights the various methods for the management of biliary leaks and postoperative biliary strictures.
M Perez-Miranda
Lecture
3 years ago
1029 views
30 likes
0 comments
26:31
Biliary access techniques in patients with surgically altered anatomy
Iatrogenic bile duct injuries following surgery are associated with life-threatening complications.
Most injuries occur following open or laparoscopic cholecystectomies. The incidence of bile duct injury (BDI) has increased when a laparoscopic approach is used.
The current incidence of BDI using a laparoscopic approach is comprised between 0.5 and 2.7%.
The presented clinical cases include bile leakage, bilioma, peritonitis or a local abscess, and only 30% of cases are recognized intraoperatively.
The main modality of treatment is surgery. However, endoscopic management is a current alternative.
This video highlights the various methods for the management of biliary leaks and postoperative biliary strictures.
Laparoscopic treatment of biliary peritonitis following complete division of posterior right lateral duct
Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Early recognition and an adequate multidisciplinary approach are the cornerstones for the optimal final outcome. This video shows the laparoscopic management of biliary peritonitis after complete division of a posterior right lateral branch.

Discussion:
The incidence of accessory hepatic ducts is reported to range from 1.4% to 27% and has been found to range from 15% to 28% in autopsy series (1,2,3).
Injury of the extra-hepatic bile ducts (BDI) is the most serious complication when performing cholecystectomy, leading to biliary leakage and peritonitis. Treatment and prevention of this complication are essential in the management of gallstone diseases. The incidence of this complication depends on local inflammation at the hepatoduodenal ligament, on the type of approach used, and on the experience of the surgeon (4,5).
Injuries of tiny posterior aberrant ducts, which enter the main duct proximal to or within the cystic duct, may accidentally occur during surgery, causing partial or total segmental duct obstruction or bile leakage. Bile duct injuries can be split into five groups according to the mechanism of etiology or to the severity of the lesion.
The most commonly used classification of acute bile duct injuries (BDI) is the one proposed by Strasberg et al. (6):
Type A: bile leak from a minor duct still in contact with the common bile duct;
Type B: occlusion of part of the biliary tree;
Type C: bile leak from the duct not in contact with the common bile duct;
Type D: lateral injury to extra-hepatic bile duct;
Type E: circumferential injury of major bile ducts.
Here, the clinical case presents a type C lesion successfully managed through a conservative surgical approach.
References:
1. Seibert D, Matulis SR, Griswold F. A rare right hepatic duct anatomical variant discovered after laparoscopic bile duct transection. Surg Laparosc Endosc 1996;6:61-4.
2. Suhocki PV, Meyers WC. Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay. AJR Am J Roentgenol 1999;172:955-9.
3. Hirao K, Miyazaki A, Fujimoto T, Isomoto I, Hayashi K. Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography. AJR Am J Roentgenol 2000;175:713-20.
4. Hugh TB. New strategies to prevent laparoscopic bile duct injury--surgeons can learn from pilots. Surgery 2002;132:826-35.
5. MacFadyen BV Jr, Vecchio R, Ricardo AE, Mathis CR. Bile duct injury after laparoscopic cholecystectomy: the United States experience. Surg Endosc 1998;12:315-21.
6. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101-25.
A D'Urso, D Mutter, J Leroy, J Marescaux
Surgical intervention
7 years ago
5296 views
41 likes
0 comments
07:42
Laparoscopic treatment of biliary peritonitis following complete division of posterior right lateral duct
Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Early recognition and an adequate multidisciplinary approach are the cornerstones for the optimal final outcome. This video shows the laparoscopic management of biliary peritonitis after complete division of a posterior right lateral branch.

Discussion:
The incidence of accessory hepatic ducts is reported to range from 1.4% to 27% and has been found to range from 15% to 28% in autopsy series (1,2,3).
Injury of the extra-hepatic bile ducts (BDI) is the most serious complication when performing cholecystectomy, leading to biliary leakage and peritonitis. Treatment and prevention of this complication are essential in the management of gallstone diseases. The incidence of this complication depends on local inflammation at the hepatoduodenal ligament, on the type of approach used, and on the experience of the surgeon (4,5).
Injuries of tiny posterior aberrant ducts, which enter the main duct proximal to or within the cystic duct, may accidentally occur during surgery, causing partial or total segmental duct obstruction or bile leakage. Bile duct injuries can be split into five groups according to the mechanism of etiology or to the severity of the lesion.
The most commonly used classification of acute bile duct injuries (BDI) is the one proposed by Strasberg et al. (6):
Type A: bile leak from a minor duct still in contact with the common bile duct;
Type B: occlusion of part of the biliary tree;
Type C: bile leak from the duct not in contact with the common bile duct;
Type D: lateral injury to extra-hepatic bile duct;
Type E: circumferential injury of major bile ducts.
Here, the clinical case presents a type C lesion successfully managed through a conservative surgical approach.
References:
1. Seibert D, Matulis SR, Griswold F. A rare right hepatic duct anatomical variant discovered after laparoscopic bile duct transection. Surg Laparosc Endosc 1996;6:61-4.
2. Suhocki PV, Meyers WC. Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay. AJR Am J Roentgenol 1999;172:955-9.
3. Hirao K, Miyazaki A, Fujimoto T, Isomoto I, Hayashi K. Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography. AJR Am J Roentgenol 2000;175:713-20.
4. Hugh TB. New strategies to prevent laparoscopic bile duct injury--surgeons can learn from pilots. Surgery 2002;132:826-35.
5. MacFadyen BV Jr, Vecchio R, Ricardo AE, Mathis CR. Bile duct injury after laparoscopic cholecystectomy: the United States experience. Surg Endosc 1998;12:315-21.
6. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101-25.
Laparoscopic transcystic and hybrid transgastric rendezvous technique for common bile duct lithiasis after gastric bypass
Common bile duct lithiasis has become a challenging problem in patients who have undergone a laparoscopic Roux-en-Y gastric bypass for morbid obesity. Altered anatomy due to gastric diversion and biliary limb reconstruction leads to a prolonged and complex access to the ampulla of Vater. Consequently, experienced endoscopists and double-balloon endoscopes are required, often making it impossible to successfully perform an endoscopic sphincterotomy as in this case.
Here, we describe the case of a patient who had already been operated on for a gastric bypass and who presented with multiple past episodes of cholangitis because of common bile duct stones. A double-balloon endoscopic sphincterotomy failed leading to the decision of surgical treatment combining a hybrid technique of laparoscopic transgastric sphincterotomy with a transcystic common bile duct exploration.
L Marx, S Tzedakis, P Pessaux, M Delvaux, D Mutter, J Marescaux
Surgical intervention
4 years ago
1154 views
45 likes
0 comments
11:34
Laparoscopic transcystic and hybrid transgastric rendezvous technique for common bile duct lithiasis after gastric bypass
Common bile duct lithiasis has become a challenging problem in patients who have undergone a laparoscopic Roux-en-Y gastric bypass for morbid obesity. Altered anatomy due to gastric diversion and biliary limb reconstruction leads to a prolonged and complex access to the ampulla of Vater. Consequently, experienced endoscopists and double-balloon endoscopes are required, often making it impossible to successfully perform an endoscopic sphincterotomy as in this case.
Here, we describe the case of a patient who had already been operated on for a gastric bypass and who presented with multiple past episodes of cholangitis because of common bile duct stones. A double-balloon endoscopic sphincterotomy failed leading to the decision of surgical treatment combining a hybrid technique of laparoscopic transgastric sphincterotomy with a transcystic common bile duct exploration.
Laparoscopic transgastric sphincterotomy for common bile duct stones
We report the case of a transgastric sphincterotomy. This is the case of a 67-year-old woman presenting with cholangitis with a past history of an esophageal peptic stenosis. After dilatation, the duodenoscopy does not make it possible to cross this stenosis. A transgastric laparoscopy is decided upon in order to introduce the duodenoscope through a 15mm port. The duodenoscope is then introduced through the port into the anterior gastric wall allowing for a successful sphincterotomy and stone extraction. The duodenoscope is withdrawn and the gastrotomy is closed. A laparoscopic cholecystectomy is performed. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6.
P Pessaux, J Huppertz, D Ntourakis, A Sportes, E Wedi, D Mutter, J Marescaux
Surgical intervention
5 years ago
2874 views
41 likes
0 comments
09:04
Laparoscopic transgastric sphincterotomy for common bile duct stones
We report the case of a transgastric sphincterotomy. This is the case of a 67-year-old woman presenting with cholangitis with a past history of an esophageal peptic stenosis. After dilatation, the duodenoscopy does not make it possible to cross this stenosis. A transgastric laparoscopy is decided upon in order to introduce the duodenoscope through a 15mm port. The duodenoscope is then introduced through the port into the anterior gastric wall allowing for a successful sphincterotomy and stone extraction. The duodenoscope is withdrawn and the gastrotomy is closed. A laparoscopic cholecystectomy is performed. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6.
Laparoscopic transcystic clearance of the common bile duct (CBD) during three-trocar cholecystectomy
Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis is established during intraoperative cholangiography, the surgeon is confronted with a therapeutic dilemma, namely the choice between laparoscopic common bile duct (CBD) exploration, conversion to open surgery, or postoperative endoscopic sphincterotomy. Laparoscopic CBD exploration can be performed through the cystic duct or through a choledochotomy, the choice being mainly guided by the size of the CBD stone and the size of the cystic duct and common bile duct. In this patient with a large cystic duct, small stone and normal CBD size, we have opted for the transcystic extraction, using the Dormia basket under fluoroscopic guidance. The procedure was performed using a three-trocar approach and a new internal retraction device that suspends the gallbladder.
B Dallemagne, T Piardi, J Marescaux
Surgical intervention
7 years ago
4045 views
20 likes
0 comments
12:26
Laparoscopic transcystic clearance of the common bile duct (CBD) during three-trocar cholecystectomy
Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis is established during intraoperative cholangiography, the surgeon is confronted with a therapeutic dilemma, namely the choice between laparoscopic common bile duct (CBD) exploration, conversion to open surgery, or postoperative endoscopic sphincterotomy. Laparoscopic CBD exploration can be performed through the cystic duct or through a choledochotomy, the choice being mainly guided by the size of the CBD stone and the size of the cystic duct and common bile duct. In this patient with a large cystic duct, small stone and normal CBD size, we have opted for the transcystic extraction, using the Dormia basket under fluoroscopic guidance. The procedure was performed using a three-trocar approach and a new internal retraction device that suspends the gallbladder.