VS 09 - HPB Laparoscopic Trans-Cystic Bile Duct Exploration is Safe and Feasible even after previous Cholecystectomy

Abstract Background Laparoscopic trans-cystic bile duct exploration is well know to have less comorbidity that conventional trans-ductal approach. A 56-year-old female underwent emergency laparoscopic cholecystectomy in 2019 for cholecystitis. Subsequently treated conservatively for ascending cholangitis due to large stone in the bile duct on MRCP. She underwent two unsuccessful ERCPs due to anatomical challenges; large hiatus hernia and duodenal diverticulum. The MDT determined bile duct exploration was necessary as no endoscopic options remained. After assessing previous imaging, laparoscopic trans-cystic exploration was chosen to minimise complications. This video highlights the feasibility of laparoscopic trans-cystic CBD post-cholecystectomy. Method Standard four-port technique with 10mm, 30-degree laparoscope. Blunt, sharp, energised and hydro-dissection were employed. Indocyanaine green(ICG) helped identify the bile duct(CBD) and the cystic duct(CD) stump. CD was dissected from the gallbladder bed and opened for a cholangiogram; confirming a large stone in the distal bile duct. A 3.5 mm choledochoscope with electrohydraulic lithotripsy(EHL) was used to explore the bile duct and fragment the stone for extraction. Remaining small fragments were flushed into the duodenum after 20mg buscopan intravenously. Final cholangioscopy and cholangiogram through the choledochoscope showed clear ducts with good flow into the duodenum. Results The patient was started on IV antibiotics due to pyrexia on the first night of admission. The abdominal drain was removed after 48 hours, and the patient was discharged on day three to complete a five-day course of antibiotics. Nine months post-operatively, she presented with a 3x5x7.5 cm sub-hepatic abscess, requiring interventional radiology (IR) drainage and a six-week course of antibiotics. The drain was removed after a follow-up CT scan three weeks post-drainage showed resolution. There have been no further episodes of cholangitis, and she has returned to her baseline quality of life. Conclusion This case shows laparoscopic trans-cystic approach remains viable post-cholecystectomy. Advanced imaging and tools including 3.5mm choledochoscope and EHL aid safer surgery with reduced morbidity, shorter stays and faster recovery. Antibiotics may be necessary for cases with longstanding bile duct stones. Furthermore, this case highlights the importance of intraoperative cholangiography and bile duct exploration. The patient had an MRCP in 2019 that showed no bile duct stones but a dilated CBD associated with deranged LFTs. This suggests that her journey might have been less complicated if a cholangiogram had been performed during the initial laparoscopic cholecystectomy.