Laproscopic management of obstructive jaundice.ppt
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Transcript of Laproscopic management of obstructive jaundice.ppt
Common Bile Duct
Exploration
LaproscopicBiliary
Drainage procedures
TRANS CYSTIC APPROACH
CHOLEDOCHOTOMY APPROACH
Insertion of suction tube in to choledochotomy with tip pointing towards ampulla
Low suction is applied and stone adheres to suction tip
Stone is delivered, transfered to spoon forceps & removed
An iv injection of glucagon relaxes ampulla which facilitate down flushing of stone in to duodenum
Deflated baloon cathter is guided in to CBD to pass across the ampulla & in duodenum
Inflated & withdrawn until resistanse is felt
Deflated & withdrawn for 1cm
Now ballon is distal CBD
Reinflated
Slowly withdrawn maintaining the inflated position to extract stone
Repeated 2 to 3 times to ensure complete clearence
Dormia basket is introduced through cystic duct or Choledocotomy
Basket guided to distal end of CBD
Slowly withdrawn while wires of basket are opened and closed to catch any stone fragments
Inability to completely close the basket –presence of stones
Basket along with stones are removed in sweeping motion
Repeated till entire CBD is free of stones
This procedure can be
performed under guidence of
ULTRASOUND
CHOLEDOCOSCOPE
This is done with a T-tube closure
Horizontal limb of T-tube is trimmed to a length of 1.5cms & filleted
T-tube is placed In to CBD through Choledocotomy
wound
Incision is then closed by two
or three interrupted
sutures
Other end of T-tube is brought
out through separate stab incision & sub
hepatic drain is placed
Left undisturbed for 2-3 weeks and then removed
Grossly dilated
common duct
Short distal stricture
with proximal dilatation
CBD incised longitudinally for 2.5cms from point at which it traverses duodenum extending proximaly
CBD thoroughly rinsed with warm normal saline
Duodenum incised longitudinally for 1.5cms along superior border
Single layered anastomosis is performed with knots on inner side
No need for T-tube drainage
If duct <2cm, distal
bile duct injury,
malignant obstruction, duodenum not suitable for choledochoduodenostomy
Duct is transected & end to side anastomosisis performed