A 27-year-old woman presented with gallstone pancreatitis. After a 36-hour cooling down period, the patient underwent laparoscopic cholecystectomy. There was a markedly dilated cystic duct shown here. The cystic artery and a small branch crossing the cystic duct have been divided. A palpable (by instrument) stone in the cystic duct was milked upward, and a single clip was placed at the junction of cystic duct and infundibulum. A small opening was made on the anterior surface of the cystic duct below the clip and a cholangiogram catheter was inserted a distance of one centimeter with the assistance of saline infusion.
7 cc of dilute contrast (50% Hypaque mixed 50/50 with saline) was slowly injected under fluoroscopic control. Four 4 mm stones were seen in the distal common duct. The ductal system was dilated, biliary radicals of all major ducts filled without filling defects and there was a trickle of contrast into the duodenum past the stones. Injection was stopped at the first evidence of pancreatic duct filling. Of interest, the anterior division of the right hepatic duct (segments V and VIII: see hepatic segmental anatomy) drained into the left hepatic duct (see biliary variation). The cholecystectomy was completed and the patient went for post operative ERCP with sphincterotomy and stone extraction.
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