OPEN CHOLECYSTECTOMY WITH COMMON BILE DUCT EXPLORATION WITH T TUBE DRAINAGE

     This procedure is done in patients with gall stone and bile duct stone where the ERCP is technically not possible. There are some situations in which second part of the duodenum cannot be reached by the duodenoscope. The common conditions are gastric outlet obstruction due to previous chronic disease like duodenal ulcer or following any previous gastric operation involving the pylorus of the stomach in which technically duodenum cannot be reached.

     Other common indication is presence of multiple large stones in the bile duct in which the ERCP cannot remove the stones from the bile duct.

        Here the procedure is same as routine open cholecystectomy. The patient is prepared for general anaesthesia with or without regional analgesia. Abdomen is opened through right sub costal incision. Gall bladder is mobilized and common bile duct area will be exposed. Bile can be aspirated with a needle from the common bile duct to confirm that it is a bile duct, and the presence of bile in the syringe confirms the same.

     Then, two stay sutures are taken over the anterior aspect of the common bile duct and bile duct is opened. Stone present in the bile ducts are removed using various instruments. Then the complete removal of stones from bile duct is confirmed with either of the two techniques. One is intra operative cholangiogram in which contrast is injected into the biliary system and imaging is done. This shows the presence of any leftover stones in the bile duct.

     Alternative technique is by doing endoscopic examination of the bile duct, the technique is called choledochoscopy. The advantage of this technique is that, it visualizes the stone in the bile duct and so the retained stones can be removed through the scope itself. After this, gall bladder removal is completed. All the bleeding points has to be arrested.

     Once all the stones get removed from common bile duct, a tube known as T tube is placed in the bile duct and bile duct is closed over the T tube with absorbable suture materials. Then the T tube is brought out through the right side of the abdominal wall. Usually, a drainage tube will be placed in the gall bladder bed and abdomen will be closed.

     The T-tube will be there for about 6 weeks. At the ned of 6 weeks, check T-tube cholangiogram will be done. Alternatively, MRCP can also be done to rule out the possibility of residual stones. If no residual stones, then the T-tube can be removed.