S u rg ica I works hop Br. J. Surg. 1992, Vol. 79, November, 1178-1179
Laparoscopic cholangiography a simple inexpensive technique using readily available materia S M. H. Harvey, J. Cahill and C . Wastell Academic Surgical Unit, Page Street Wing, Westminster Hospital, London S W l P 2AP. UK Correspondence to: Mr M. H. Harvey
Experience of laparoscopic cholecystectomy has increased rapidly since the operation was first performed in France in 1987; approximately 20 000 operations have been performed in the USA alone'. Laparoscopic cholecystectomy is now the treatment of choice for patients with symptomatic gallstones'. Opinion is, however, divided as to the need for routine peroperative ~holangiography~. Even when a selective policy is adopted, cholangiography will be necessary in certain cases, particularly when ductal anatomy is unclear or common bile duct (CBD) stones are predicted. Unexpected CBD stones can be anticipated in 4-10 per cent of cases4. A number of specially designed cholangiography catheters and clamps are available for use in laparoscopic cholecystectomy, but they are expensive and not always readily available. For laparoscopic cholangiography in this unit, two simple inexpensive pieces of equipment that should be available in any operating theatre are used.
Surgical technique The cystic duct is cleared of fat from its junction with the gallbladder to that with the common hepatic duct. A clip is placed on the gallbladder side of the cystic duct and the latter is opened with microscissors. A 14-Fr Abbocath cannula (Abbott Laboratories, Queenborough, Kent, UK) is inserted percutaneously under direct vision into the abdomen in the right upper quadrant just below the costal margin. The needle is withdrawn and a 4-Fr olive-tipped ureteric catheter (Porges; Uroplast, Windsor, UK) with its steel stylet in place is inserted through the cannula into the abdomen. The lower end of the cannula
is gently held with a grasping forceps and guided to the hole in the cystic duct. Once over this hole the ureteric catheter can be manoeuvred easily into the duct (Figure I ) . The stylet on the catheter aids passage through the spiral valve of Heister. The stylet is withdrawn, and the ureteric catheter is held in place by a second clip applied just firmly enough to stop it slipping out, but not so tightly as to cause occlusion. A 20-ml syringe filled with saline is attached to the catheter, and the cystic duct and CBD are flushed with saline. Radiological contrast is then injected under image intensification control. Once satisfactory cholangiograms have been obtained, the clip securing the ureteric catheter is removed and the catheter is withdrawn. Two clips are placed on the bile duct side of the hole in the cystic duct, and the latter is divided with microscissors.
Results A total of 58 peroperative cholangiograms have been performed using this technique during 180 laparoscopic cholecystectomies. Success was obtained in 51 cases (88 per cent). Failure to obtain a satisfactory cholangiogram was caused by extravasation of contrast (three patients) and failure to negotiate the spiral valve (three). In a further case the tip of the ureteric catheter was found on screening to be in the duodenum and fell out of the cystic duct on withdrawal; the procedure was not repeated. Peroperative cholangiography was normal in 43 of 51 cases. CBD stones were detected in seven patients and were dealt with by postoperative endoscopic sphincterotomy and stone extraction. A further patient had abnormal ductal anatomy.
Discussion Although not all surgeons practise routine peroperative cholangiography during open cholecystectomy, we feel that it is desirable to do so in the laparoscopic operation, particularly early in the surgeon's experience when orientation and identification of the anatomy in Calot's triangle may not be entirely clear. In spite of not being specifically designed for cholangiography, ureteric catheters have been used by many surgeons for cholangiography during open cholecystectomy and have been found satisfactory for the purpose. A 4-Fr ureteric catheter fits snugly into a 14-Fr Abbocath cannula, and no problems have been experienced with loss of carbon dioxide. Both items are readily available and are much cheaper than the catheters and clamps that have been specificallydesigned for peroperative cholangiography .
Figure 1 The Abbocath cannula is guided to an incision in the cystic duct, and a 4-Fr ureteric catheter is inserted into the duct through the cannula. The ureteric catheter is held in position with a clip
1178
ooO7-1323/92/11117&02
0 1992 Butterworth-Heinemann
Ltd
Surgical workshop
References 1. 2.
3.
Schirmer BD, Edge SB, Dix J et ul. Laparoscopic cholecystectomy. Ann Surg 1991; 213: 665-77. Wastell C. Laparoscopic cholecystectomy: better for patients and the health service. BMJ 1991; 302: 303-4. Wilson TG, Hall JC, Watts JMcK. Is operative cholangiography
4.
always necessary? Br J S l u g 1986; 73: 63740. Berci G, Hamlin JA. Unsuspected stones. In: Berci G, Hamlin JA, eds. 0perutil;e Biiiary Radiology. Baltimore: Williams and Wilkins, 1981: 137.
Paper accepted 25 April 1992
Short note Br. J. Surg. 1992, Vol. 79, November, 1179-1180
Endoscopic sphincterotomy, nasobiliary drainage and biliary stent placement without image intens if icat ion S. P. Misra, S. K. Agarwal and A. Gupta* Departments of Gastroenterology and *Radiology, Moti LalNehru Medical College, Allahabad217 001, India Correspondence to: Dr S. P. Misra
Endoscopic sphincterotomy (ES) is a useful therapeutic procedure in the management of choledocholithiasis’3z, gallstone p a n ~ r e a t i t i s ~ ’acute ~, cholangitis’ and biliary d y ~ k i n e s i a ~Nasobiliary -~. drainage and biliary stent placement These treatments are USUalb’ complement this carried out using an image intensifier, but such equipment is expensive and may not be available in developing countries. Methods and results of ES, nasobiliary drainage and biliary stent placement performed without the aid of an image intensifier are reported.
Figure 1 Nasobiliary drainage in a patient with choledocholithiasis and ucute tholungiris
Patients and methods Between January 1990 and August 1991, 175 consecutive patients suspected of having pancreatobiliary disorders underwent endoscopic retrograde cholangiopancreatography (ERCP). Nineteen patients underwent ES, five nasobiliary drainage and six had biliary stents placed. All procedures were performed by one endoscopist without the aid of an image intensifier. ES was performed using an Olympus KD-22Q (Olympus, Tokyo, Japan 1 papillotome and electrosurgical unit (Olympus PSD-2/UES10).The position of the papillotome was confirmed by injecting a small amount of contrast material and exposing a film. When the common bile duct (CBD) was clearly visualized, the papillotome was withdrawn, leaving 50 per cent of the papillotome wire visible outside the papilla. It was then bowed and the papilla cut using blended diathermy current. Patients were observed for at least 24 h and if no complications were noted were discharged. ERCP was performed 2-3 weeks later to check for ductal clearance in patients with choledochohthiasis.
Results ERCP was successful in 168 patients (96 per cent). Two attempts were required in four patients; six of the seven failures were encountered in the first ten patients. ES was performed successfully in 17 patients but the papillotome could not be positioned in the CBD in two. The 13 patients with choledocholithiasis in whom ES was performed had the CBD cleared of stones. One patient in whom ES was performed for suspected gallstone-induced acute pancreatitis improved dramatically after sphincterotomy and recovered completely.
0007-1323/92/111179%02
0 1992 Butterworth-Heinemann
Ltd
Figure 2 Biliary .stent in u patient with carcinoma pancreas
of
the heud of the
ES was also successful in a patient with periampullary carcinoma in facilitating biopsy of the tumour and in two other patients for placement of biliary stents. No procedure-related complications were seen. Nasobiliary drainage was successfully carried out in five patients using a
1179
Laparoscopic cholangiography a simple inexpensive technique using readily available materia S M. H. Harvey, J. Cahill and C . Wastell Academic Surgical Unit, Page Street Wing, Westminster Hospital, London S W l P 2AP. UK Correspondence to: Mr M. H. Harvey
Experience of laparoscopic cholecystectomy has increased rapidly since the operation was first performed in France in 1987; approximately 20 000 operations have been performed in the USA alone'. Laparoscopic cholecystectomy is now the treatment of choice for patients with symptomatic gallstones'. Opinion is, however, divided as to the need for routine peroperative ~holangiography~. Even when a selective policy is adopted, cholangiography will be necessary in certain cases, particularly when ductal anatomy is unclear or common bile duct (CBD) stones are predicted. Unexpected CBD stones can be anticipated in 4-10 per cent of cases4. A number of specially designed cholangiography catheters and clamps are available for use in laparoscopic cholecystectomy, but they are expensive and not always readily available. For laparoscopic cholangiography in this unit, two simple inexpensive pieces of equipment that should be available in any operating theatre are used.
Surgical technique The cystic duct is cleared of fat from its junction with the gallbladder to that with the common hepatic duct. A clip is placed on the gallbladder side of the cystic duct and the latter is opened with microscissors. A 14-Fr Abbocath cannula (Abbott Laboratories, Queenborough, Kent, UK) is inserted percutaneously under direct vision into the abdomen in the right upper quadrant just below the costal margin. The needle is withdrawn and a 4-Fr olive-tipped ureteric catheter (Porges; Uroplast, Windsor, UK) with its steel stylet in place is inserted through the cannula into the abdomen. The lower end of the cannula
is gently held with a grasping forceps and guided to the hole in the cystic duct. Once over this hole the ureteric catheter can be manoeuvred easily into the duct (Figure I ) . The stylet on the catheter aids passage through the spiral valve of Heister. The stylet is withdrawn, and the ureteric catheter is held in place by a second clip applied just firmly enough to stop it slipping out, but not so tightly as to cause occlusion. A 20-ml syringe filled with saline is attached to the catheter, and the cystic duct and CBD are flushed with saline. Radiological contrast is then injected under image intensification control. Once satisfactory cholangiograms have been obtained, the clip securing the ureteric catheter is removed and the catheter is withdrawn. Two clips are placed on the bile duct side of the hole in the cystic duct, and the latter is divided with microscissors.
Results A total of 58 peroperative cholangiograms have been performed using this technique during 180 laparoscopic cholecystectomies. Success was obtained in 51 cases (88 per cent). Failure to obtain a satisfactory cholangiogram was caused by extravasation of contrast (three patients) and failure to negotiate the spiral valve (three). In a further case the tip of the ureteric catheter was found on screening to be in the duodenum and fell out of the cystic duct on withdrawal; the procedure was not repeated. Peroperative cholangiography was normal in 43 of 51 cases. CBD stones were detected in seven patients and were dealt with by postoperative endoscopic sphincterotomy and stone extraction. A further patient had abnormal ductal anatomy.
Discussion Although not all surgeons practise routine peroperative cholangiography during open cholecystectomy, we feel that it is desirable to do so in the laparoscopic operation, particularly early in the surgeon's experience when orientation and identification of the anatomy in Calot's triangle may not be entirely clear. In spite of not being specifically designed for cholangiography, ureteric catheters have been used by many surgeons for cholangiography during open cholecystectomy and have been found satisfactory for the purpose. A 4-Fr ureteric catheter fits snugly into a 14-Fr Abbocath cannula, and no problems have been experienced with loss of carbon dioxide. Both items are readily available and are much cheaper than the catheters and clamps that have been specificallydesigned for peroperative cholangiography .
Figure 1 The Abbocath cannula is guided to an incision in the cystic duct, and a 4-Fr ureteric catheter is inserted into the duct through the cannula. The ureteric catheter is held in position with a clip
1178
ooO7-1323/92/11117&02
0 1992 Butterworth-Heinemann
Ltd
Surgical workshop
References 1. 2.
3.
Schirmer BD, Edge SB, Dix J et ul. Laparoscopic cholecystectomy. Ann Surg 1991; 213: 665-77. Wastell C. Laparoscopic cholecystectomy: better for patients and the health service. BMJ 1991; 302: 303-4. Wilson TG, Hall JC, Watts JMcK. Is operative cholangiography
4.
always necessary? Br J S l u g 1986; 73: 63740. Berci G, Hamlin JA. Unsuspected stones. In: Berci G, Hamlin JA, eds. 0perutil;e Biiiary Radiology. Baltimore: Williams and Wilkins, 1981: 137.
Paper accepted 25 April 1992
Short note Br. J. Surg. 1992, Vol. 79, November, 1179-1180
Endoscopic sphincterotomy, nasobiliary drainage and biliary stent placement without image intens if icat ion S. P. Misra, S. K. Agarwal and A. Gupta* Departments of Gastroenterology and *Radiology, Moti LalNehru Medical College, Allahabad217 001, India Correspondence to: Dr S. P. Misra
Endoscopic sphincterotomy (ES) is a useful therapeutic procedure in the management of choledocholithiasis’3z, gallstone p a n ~ r e a t i t i s ~ ’acute ~, cholangitis’ and biliary d y ~ k i n e s i a ~Nasobiliary -~. drainage and biliary stent placement These treatments are USUalb’ complement this carried out using an image intensifier, but such equipment is expensive and may not be available in developing countries. Methods and results of ES, nasobiliary drainage and biliary stent placement performed without the aid of an image intensifier are reported.
Figure 1 Nasobiliary drainage in a patient with choledocholithiasis and ucute tholungiris
Patients and methods Between January 1990 and August 1991, 175 consecutive patients suspected of having pancreatobiliary disorders underwent endoscopic retrograde cholangiopancreatography (ERCP). Nineteen patients underwent ES, five nasobiliary drainage and six had biliary stents placed. All procedures were performed by one endoscopist without the aid of an image intensifier. ES was performed using an Olympus KD-22Q (Olympus, Tokyo, Japan 1 papillotome and electrosurgical unit (Olympus PSD-2/UES10).The position of the papillotome was confirmed by injecting a small amount of contrast material and exposing a film. When the common bile duct (CBD) was clearly visualized, the papillotome was withdrawn, leaving 50 per cent of the papillotome wire visible outside the papilla. It was then bowed and the papilla cut using blended diathermy current. Patients were observed for at least 24 h and if no complications were noted were discharged. ERCP was performed 2-3 weeks later to check for ductal clearance in patients with choledochohthiasis.
Results ERCP was successful in 168 patients (96 per cent). Two attempts were required in four patients; six of the seven failures were encountered in the first ten patients. ES was performed successfully in 17 patients but the papillotome could not be positioned in the CBD in two. The 13 patients with choledocholithiasis in whom ES was performed had the CBD cleared of stones. One patient in whom ES was performed for suspected gallstone-induced acute pancreatitis improved dramatically after sphincterotomy and recovered completely.
0007-1323/92/111179%02
0 1992 Butterworth-Heinemann
Ltd
Figure 2 Biliary .stent in u patient with carcinoma pancreas
of
the heud of the
ES was also successful in a patient with periampullary carcinoma in facilitating biopsy of the tumour and in two other patients for placement of biliary stents. No procedure-related complications were seen. Nasobiliary drainage was successfully carried out in five patients using a
1179
