Novel Use of Intraoperative Fluoroscopy in an Era of ICG for Complex Laparoscopic Cholecystectomy

Background  Laparoscopic cholecystectomy (LC) is increasingly being used as a first-line treatment for acute cholecystitis. Bile duct injury (BDI) remains the most feared complication of the minimally invasive approach specially in cases with an inflamed calots triangle. While use of indocyanine dye (ICG) to delineate biliary anatomy serves to reduce BDI, the high cost of the technology prohibits its use in the developing world. We propose a novel use of common bile duct (CBD) stenting preoperatively in cases of cholecystitis secondary to choledocholithiasis as a means of identification and safeguarding the CBD.

Methods  A retrospective review was conducted on 22 patients of Grade 2 or Grade 3 cholecystitis who underwent an early LC at our institution. All patients were stented preoperatively and the stent was used for a much-needed tactile feedback during dissection. A c-arm with intraoperative fluoroscopy was used to identify the CBD prior to clipping of the cystic duct.

Results  The gall bladder was gangrenous in all the cases while two cases had evidence of end organ damage. This innovative use of CBD stenting allowed us to correctly delineate biliary anatomy in all of the cases and we report no instances of BDI despite a severely inflamed local environment.

Conclusion  This technique can become a standard of care in all teaching institutions in developing countries further enhancing the safety of cholecystectomy in gangrenous cholecystitis with a distorted biliary anatomy.

De novo Choledocholithiasis in Retained Common Bile Duct Stent

De novo choledocholithiasis means formation of stone in the common bile duct (CBD). It can present as biliary colic, jaundice, cholangitis, pancreatitis or it may be asymptomatic. There are various indications for biliary stenting like CBD stone, CBD stricture, biliary leak, peri ampullary carcinoma, CBD malignancy, etc. Foreign bodies like silk sutures, endo-clips, fish bone, retained T- tubes, plastic or metallic stents, etc. lead to biliary stasis leading to eventual stone formation. Here, we discuss a case of choledocholithiasis post-cholecystectomy with CBD stenting done 15 years back which had migrated and acted as a nidus for stone formation in the CBD and hepatic duct.