Laparoscopic common

bile duct exploration

LCBDE))
 introduction

Common bile duct stones (CBD) stones may

occur in 3% to 14.7% of all patients for
whom cholecystectomy is preformed

Schirmer et al., 2005

 introduction

Different methods have been used for the

treatment of (CBD) stones but the suitable
therapy depends on conditions such as
patient’ satisfaction, number and size of
stones, and the surgeons experience in
.laparoscopy

.)Carr-Locke, 2006(
 Anatomy Of The Extra hepatic
Biliary System
The extrahepatic bile ducts are represented by
• the extrahepatic segments of the right and left
hepatic ducts joining to form the biliary
confluence and
• the main biliary channel draining to the
duodenum.
• The accessory biliary apparatus, which
constitutes a reservoir, comprises the
gallbladder and cystic duct

.)Blumgart and Hann, 2007(

.)Ellis, 2006(
 Anatomy Of The Extra hepatic
Biliary System
Common Bile Duct (Ductus Choledochus)
• The common bile duct begins at the union of the cystic
and common hepatic ducts and ends at the papilla of
Vater in the second part of the duodenum
• The common bile duct can be divided into four portions
or segments
1. The supraduodenal portion
2. the retroduodenal portion
3. the pancreatic portion
4. the intramural portion

(Skandalakis et al., 2000).

 Classification and incidence of
Choledocholithiasis
:Primary
Primary bile duct stones are
formed in the intrahepatic
or extrahepatic bile ducts.
They are more prevalent
in Asian populations.
These stones usually are
brown pigment stones.
Bacterial colonization of
bile and bile stasis play
important roles in the
pathogenesis of these
stones
Secondary bile duct stones
In the Western world, most
stones in the common bile
duct arise from the passing
of gallbladder stones into
the common bile duct.
Stones in the common duct
occur in 10% to 15% of
people who have
.gallbladder stones
.)Ko and Lee, 2002(
 Pathophysiology of Bile Duct
Obstruction
Bile duct obstruction can affect hepatic
hemodynamics significantly. In general, liver
blood flow (LBF) is reduced in the presence of
chronic biliary obstruction. Reduction of LBF in
this setting may contribute to hepatic
dysfunction. Conversely, acute increases in bile
duct pressure after obstruction result in a
reactive increase in LBF, which may represent
an attempt by the liver to maintain adequate
function against an increase in the pressure
gradient opposing secretion and excretion of bile

.)Blumgart et al., 2007(

 Biliary-Induced Hepatic Atrophy

The molecular mechanisms involved in

biliary obstruction leading to hepatic
atrophy are much more centered on
apoptosis, with little or no involvement of
acute necrosis. Cholestasis results in the
accumulation of toxic bile salts, which
induce apoptosis

.)Gujral et al, 2004(

 Clinical Picture
• Asymptomatic,
• sudden toxic cholangitis,
• biliary colic
• pruritus
• jaundice
• pancreatitis

.)Lauter and Froines, 2000(

 Blood Tests
Patients presenting with CBDS often have
• cholestatic liver function tests (LFT’s).
• Elevated serum gamma glutamyl
transpeptidase (GGT) and
• Elevated serum alkaline phosphatase
(ALP) were the most frequent biochemical
abnormalities in patients with symptomatic
choledocholithiasis (increased in 94% and
91% of cases, respectively)
.)Caddy and Tham, 2006
 Imaging Modalities
Transabdominal ultrasound (TUS)

:Computed tomography (CT)

Magnetic Resonance
:Cholangiopancreatography (MRCP)
Endoscopic retrograde cholangiography
(ERC)
Endoscopic Ultrasound (EUS)