c l i n i c a l f o l i o s : n a r r a t i v e





A D V E R T I S E M E N T

 

Retained Common Duct Stone: 1

A D V E R T I S E M E N T

   
 

A 72-year-old woman presented with symptomatic cholelithiasis. She had had multiple episodes of biliary colic and one hospitalization for cholecystitis. She was not operated on at that time because she had had an acute MI four months previously and was considered high risk. Her liver enzymes, bilirubin, amylase and lipase were normal. At 6 months post-MI she was taken to the operating room for elective laparoscopic cholecystectomy (see laparoscopic cholecystectomy and laparoscopic cholecystectomy video). The gallbladder was thickened and encased in dense adhesions. A large tubular structure (shown) thought to be cystic duct (see biliary variation, frame 12) was visualized with difficulty. The structure was confirmed to be biliary rather than arterial by percutaneous aspiration with a long 22g spinal needle.   

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Retained Common Duct Stone: 2

A D V E R T I S E M E N T

   
 

An intraopertive cholangiogram (IOC) (see cystic duct cholangiogram and discussion) was then performed to confirm the isolated structure was cystic duct and not a major bile duct (common duct, accessory or replaced right hepatic duct, see biliary variation, frame 6). Two gentle (to avoid pancreatic duct reflux), successive injections of seven cc of 25% contrast solution were performed. The structure was confirmed to be a large cystic duct running a spiral course (see biliary variation, frame 11) to enter low behind the common duct (note double shadow). The common hepatic duct and bifurcation of right and left hepatic ducts were visualized and no proximal filling defect was seen.    

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Retained Common Duct Stone: 3

A D V E R T I S E M E N T

   
 

A single 6-mm common duct stone was visualized at the ampulla of Vater. No contrast got past the stone into the duodenum. Due to the patient’ heart condition, the length of time it took to dissect out the gallbladder and some lability of the patient's blood pressure, it was elected to not attempt choledochoscopic stone extraction at this time, and to plan endoscopic retrograde cholangiopancreatographic (ERCP) (see common duct stones and ERCP discussion) stone extraction on the day following surgery. The laparoscopic cholecystectomy was completed.     

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This page was last modified on 2/3/2004.