A surgeon is performing laproscpic cholecys-tectomy with no experience of laproscopic chol-edocholithotomy, found CBD stone during lapro-scopic surgery, what would you advise him ?
|A||Laparoscopic cholecystectomy & CBD stone extraction|
|B||Laparoscopic cholecystectomy & choledochostomy|
|C||Do open cholecystectomy & CBD stone extraction|
|D||Do open cholecystectomy and choledochoduoden-ostomy|
(Ref: Swartz surgery, 8th edition, page 1205)
Diagnosis of co-incident CBD stone can be made pre operatively on USG, elevated alkaline phosphatase or dilated CBD.
Intraoperative diagnosis of CBD stone can be made by visible dilatation of duct, palpable CBD stone.
If the diagnosis is made pre-operatively, then the treatment of choice is pre-operative ERCP and temporary starring or papillotomy or sphincterotomy.
If the diagnosis is made intraoperatively it depends on.
a. Type of surgery i.e. open vs laparoscopy
b. Expertise of the surgeon
c. Presence of pericholedochocystic inflammation.
i. If the approach is laparoscopic & surgeon is expertise is laparoscopic surgery and there are no pericholedochocystic inflammation the surgery can proceed laparoscopically for cholecystectomy and stone retrieval.
ii. It case of inadequate experience of surgeon or presence of disease ,adhesion around CBD, the surgery should be a open cholecystectomy.
iii. If the diagnosis is made post operatively, then the only approach most feasible is post operatively ERCP and stenting.