During laparoscopic cholecystectomy, unexpected findings may mandate immediate intraluminal
biliary visualization for safe patient management. We evaluated percutaneous cholangioscopy
in two whole-body donors.
After preparation of the hilus, the sterile, single-use, 11 Fr, single-operator cholangioscope,
with working channels for guidewire (or instruments) and irrigation (SpyGlass DS;
Boston Scientific, Ratingen, Germany), was advanced through one of the trocars from
the right lateral flank ([Fig. 1 a]). Intra-abdominal navigation toward the biliary entry site (cystic duct or choledochotomy)
was achieved through a combination of trocar guidance, laparoscopic forceps, and the
endoscope hand wheels ([Fig. 1 b], [Video 1]). Wire insertion from the cholangioscope into the entry site facilitated navigation.
Intraoperative visualization was mimicked by access through the cystic duct toward
the papilla ([Fig. 2 a]), and through the choledochotomy toward the papilla, and across the hilus to the
segmental branchings ([Fig. 2 b]). In one case, a thin cystic duct did not allow entry of the cholangioscope, so
choledochotomy was performed. In the other donor, although vision was blurred by postmortem-thickened
bile, small stones could be flushed out of the common bile duct (CBD), indicating
that cholangioscopy was able to provide basic therapy. No fluoroscopy control was
needed. Choledochoscopy was available within 5 minutes from opening the biliary access
site. Access sites were closed by single-button sutures (choledochotomy) or two titanium
clips (cystic duct).
Fig. 1 Percutaneous choledochoscopy. a The cholangioscope was manually advanced through the trocar on the right side; the
inset shows the cholangioscopic view within the trocar. b The cholangioscope was maneuvered through the inflated abdominal cavity by a combination
of laparoscopic forceps guidance, endoscopic hand wheels, and wire guidance.
Video 1: Laparoscopic preparation of the hilus was performed using three working trocars
and one per-umbilical camera trocar. After visualization of Calot’s triangle, two
access routes were explored: the stump of the cystic duct and intrabiliary endoscopy
via a small choledochotomy.
Fig. 2 Intraoperative visualization during percutaneous choledochoscopy. a Cholangioscopic view of wire-guided advancement into the distal common bile duct
from a proximal entry site. b Left liver segmental ducts.
Laparoscopically guided choledochoscopy provides a fast, simple, sterile, and radiation-free
method for direct intraoperative visualization of the biliary ducts. Although our
data are still preliminary, this single-step, laparoscopic-endoscopic rendezvous may
allow a minimally invasive, interdisciplinary strategy for selected patients. Possible
indications include: 1) laparoscopic-endoscopic CBD stone clearance after failed endoscopic
removal or intraoperatively identified CBD stones [1]
[2]; 2) laparoscopic CBD closure without T-tube after ensuring CBD integrity endoscopically
via the cystic duct and, if necessary, simultaneous sphincterotomy [3]
[4]
[5]; and 3) management of unexpected Mirizzi syndrome with stone penetration.
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