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Choledochoscopy model
MODERN OPERATIVE TECHNIQUES
Choledochoscopy Model
James P. Moss, MD, FACS, Louisville,
Kentucky
The principal value of choledochoscopy, when combined with sound clinical judgment and operative cholangiography, lies in reducing the incidence of retained stones to less than 1 percent. When retained stones occur, nonoperative removal can usually be accomplished by the technique of basket catheter extraction reported by Burhenne [I], by using the specially designed forceps of Mazzarello [Z], or by postoperative fiberoptic choledochoscopy described by Moss et al [3] and Whelan and Moss [4]. Despite these advances, the optimal management of retained calculi is unquestionably their prevention by the complete removal of all stones during the initial biliary tract procedure. Schein [5] describes 117 primary explorations of the common duct where the potential retained calculus incidence of 5.1 percent by standard techniques was reduced to 0.9 percent by the use of endoscopy. The addition of biliary endoscopy to the operative procedure has not increased the morbidity of choledocholithotomy
cious lesions on the T-tube cholangiogram which were not apparent on operative cholangiograms. The instruction of residents during surgery in the use of the choledochoscope and its accessories has been difficult because of the number of cases available and the demands of surgery. The surgeon who has learned biliary endoscopy through clinical use may spend many months before becoming adept and confident with the choledochoscope. In a review of 144 instances of choledochoscopy, Rattner [7] concludes that the failure of choledochoscopy to prevent retained stones can be largely attributed to “inexperience of surgeons learning to perform biliary endoscopy . . . and failure to scan the biliary tree systematically and thoroughly.” Prior experience with models for teaching bronchoscopy indicate that proficiency can be improved
b31. The second clinical application of choledochoscopy has resulted from its usefulness in providing additional information to the surgeon during operations for biliary strictures or for neoplasms of the bile ducts and ampulla. The third application of choledochoscopy is the removal of retained stones through the T-tube tract under precise visual control. Preliminary reports indicate successful extraction equal to and exceeding other techniques. Postoperative choledochoscopy also makes possible evaluation and biopsy of suspiFrom the University of LouisvilleSchool of Medicine, Department of Surgery, Louisville, Kentucky. Requests fcf reprints should be addressed to James P. Moss. MD, 250 East Liberty Street, Louisville, Kentucky 40202.
374
Figure 1. Emloecoplc mode!
forchohdochoscopy.
The American Journal of Surgery
Choledochoscopy
F@we 2. EniWcopk
appearance of a jwwged forceps engagtng
8 stone. Ftgure 2. Endoscopk vfew of 8 stone in a splr8l basket inserted through a choledochoscope.
and training time reduced with their use [8]. A teaching model (Meditech, Watertown, Massachusetts) which duplicates the anatomy and endoscopic appearance of the biliary tree has been introduced as an aid for the development of skills in choledochoscopy (Figure 1). The appearance of stones within the model parallels that of surgery (Figure 2). A clear view of instruments is possible as they are manipulated to engage stones (Figure 3).
Before attempting choledochoscopy, the surgeon must be familiar with the operation of the choledochoscope and the anatomy of the biliary tree (Figure 4). Although the anatomy varies, the left lobe of the liver is divided into medial and lateral portions, each containing a superior and inferior segment. The right lobe is divided into anterior and posterior portions, each with a superior and inferior segment. Thus the
,-
RIGHT DUCT OF CAUDATE LOBE
ANTERIOR SUP. DUCT POSTERIOR SUP. DUCT POSTERIOR SUP. SEG. AL SUP. DUCT SUP. DUCT
POSTERIOR BRANCH
NF. DUCT ANTERIOR BRANCH
\-\\y
‘#LATERAL
BRANCH --
MEDIAL BRANCH
LEFT HEPATIC DUCT MEDIAL INF. SEG. COMMON HEPATIC DUCT POSTERIOR INF. DUCT ANTERIOR INF. DUCT y/,, RIGHT HEPATIC DUCT+
\
,+,
;;I;,lzEG,
’ - -f
POSTERIOR INF. SEG.
Figure 4. Anatomy of the Ilver
VOW
143, March 1992
and bltlary
tree.
375
Moss
liver has four divisions, each containing a superior and an inferior duct. With this knowledge and the ability to manipulate the endoscope, an appropriate manner to begin choledochoscopy is by endoscopic inspection at the completion of a standard common duct exploration. With increasing confidence and skill, use of the endoscope can be effectively combined with spiral baskets, pronged forceps, and so on, for the removal of stones identified on operative cholangiography. It is with this use of the choledochoscope combined with operative cholangiography that optimal results can be obtained in eliminating retained stones. The most complex use of the choledochoscope, applicable only to fiberoptic choledochoscopy, is the postoperative extraction of retained stones through the T-tube tract. This should not be attempted before acquiring the necessary experience with the instrument. This sequential approach to performing choledochoscopy is directly applicable to the biliary endoscopy model, and its use will facilitate the acquisition of skills in choledochoscopy for both residents and practicing surgeons. Summary Choledochoscopy is effective in reducing the incidence of retained biliary stones and for the removal
376
of retained calculi through the T-tube tract. It has also been of value in performing complex reconstructive and diversionary procedures on the common duct. Knowledge of the biliary anatomy is a prerequisite for the development of skill in choledochoscopy. The use of a biliary endoscopy teaching model with stones has been very effective in teaching the techniques of biliary endoscopy. Experience with the choledochoscope and its accessories should precede its use for postoperative choledochoscopy. References 1. Burhenne HJ. Nonoperative retained biliary stone extraction: a new roentgenologic technique. AJR 1973;117:388-90. 2. Mazzarello Ft. Review of 220 cases of residual biliary tract calculi treated without reoperation: an eight-year study. Surgery 1973;73:299-306. 3. Moss JP, Whelan JG, Powell RW, Dedman TC, Oliver WJ. Postoperative choledochoscopy via the T-tube tract. JAMA 1976;236:2781-2. 4. Whelan JG. Moss JP. Biliary tract exploration via T-tube tract: improved techniaue. AJR 1979:133:837-42. 5. Schetn CJ. Biliary endoscopy: an appraisal of its value in biliary lithiasis. Surgery 1969;65:1004-6. 6. Shore JM, Berci G, Morgenstern L. The value of biliary endoscopy. Surg Gynecol Obstet 1975; 140:60 l-4. 7. Rattner DW, Warshaw AL. Impact of choledochoscopy on the management of choledocholithiasis. Ann Surg 1981; 194: 76-9. 8. King EG. A teaching model for bronchoscopy. Chest 1976;70: 72-3.
The American Journal of Surgery
Choledochoscopy Model
James P. Moss, MD, FACS, Louisville,
Kentucky
The principal value of choledochoscopy, when combined with sound clinical judgment and operative cholangiography, lies in reducing the incidence of retained stones to less than 1 percent. When retained stones occur, nonoperative removal can usually be accomplished by the technique of basket catheter extraction reported by Burhenne [I], by using the specially designed forceps of Mazzarello [Z], or by postoperative fiberoptic choledochoscopy described by Moss et al [3] and Whelan and Moss [4]. Despite these advances, the optimal management of retained calculi is unquestionably their prevention by the complete removal of all stones during the initial biliary tract procedure. Schein [5] describes 117 primary explorations of the common duct where the potential retained calculus incidence of 5.1 percent by standard techniques was reduced to 0.9 percent by the use of endoscopy. The addition of biliary endoscopy to the operative procedure has not increased the morbidity of choledocholithotomy
cious lesions on the T-tube cholangiogram which were not apparent on operative cholangiograms. The instruction of residents during surgery in the use of the choledochoscope and its accessories has been difficult because of the number of cases available and the demands of surgery. The surgeon who has learned biliary endoscopy through clinical use may spend many months before becoming adept and confident with the choledochoscope. In a review of 144 instances of choledochoscopy, Rattner [7] concludes that the failure of choledochoscopy to prevent retained stones can be largely attributed to “inexperience of surgeons learning to perform biliary endoscopy . . . and failure to scan the biliary tree systematically and thoroughly.” Prior experience with models for teaching bronchoscopy indicate that proficiency can be improved
b31. The second clinical application of choledochoscopy has resulted from its usefulness in providing additional information to the surgeon during operations for biliary strictures or for neoplasms of the bile ducts and ampulla. The third application of choledochoscopy is the removal of retained stones through the T-tube tract under precise visual control. Preliminary reports indicate successful extraction equal to and exceeding other techniques. Postoperative choledochoscopy also makes possible evaluation and biopsy of suspiFrom the University of LouisvilleSchool of Medicine, Department of Surgery, Louisville, Kentucky. Requests fcf reprints should be addressed to James P. Moss. MD, 250 East Liberty Street, Louisville, Kentucky 40202.
374
Figure 1. Emloecoplc mode!
forchohdochoscopy.
The American Journal of Surgery
Choledochoscopy
F@we 2. EniWcopk
appearance of a jwwged forceps engagtng
8 stone. Ftgure 2. Endoscopk vfew of 8 stone in a splr8l basket inserted through a choledochoscope.
and training time reduced with their use [8]. A teaching model (Meditech, Watertown, Massachusetts) which duplicates the anatomy and endoscopic appearance of the biliary tree has been introduced as an aid for the development of skills in choledochoscopy (Figure 1). The appearance of stones within the model parallels that of surgery (Figure 2). A clear view of instruments is possible as they are manipulated to engage stones (Figure 3).
Before attempting choledochoscopy, the surgeon must be familiar with the operation of the choledochoscope and the anatomy of the biliary tree (Figure 4). Although the anatomy varies, the left lobe of the liver is divided into medial and lateral portions, each containing a superior and inferior segment. The right lobe is divided into anterior and posterior portions, each with a superior and inferior segment. Thus the
,-
RIGHT DUCT OF CAUDATE LOBE
ANTERIOR SUP. DUCT POSTERIOR SUP. DUCT POSTERIOR SUP. SEG. AL SUP. DUCT SUP. DUCT
POSTERIOR BRANCH
NF. DUCT ANTERIOR BRANCH
\-\\y
‘#LATERAL
BRANCH --
MEDIAL BRANCH
LEFT HEPATIC DUCT MEDIAL INF. SEG. COMMON HEPATIC DUCT POSTERIOR INF. DUCT ANTERIOR INF. DUCT y/,, RIGHT HEPATIC DUCT+
\
,+,
;;I;,lzEG,
’ - -f
POSTERIOR INF. SEG.
Figure 4. Anatomy of the Ilver
VOW
143, March 1992
and bltlary
tree.
375
Moss
liver has four divisions, each containing a superior and an inferior duct. With this knowledge and the ability to manipulate the endoscope, an appropriate manner to begin choledochoscopy is by endoscopic inspection at the completion of a standard common duct exploration. With increasing confidence and skill, use of the endoscope can be effectively combined with spiral baskets, pronged forceps, and so on, for the removal of stones identified on operative cholangiography. It is with this use of the choledochoscope combined with operative cholangiography that optimal results can be obtained in eliminating retained stones. The most complex use of the choledochoscope, applicable only to fiberoptic choledochoscopy, is the postoperative extraction of retained stones through the T-tube tract. This should not be attempted before acquiring the necessary experience with the instrument. This sequential approach to performing choledochoscopy is directly applicable to the biliary endoscopy model, and its use will facilitate the acquisition of skills in choledochoscopy for both residents and practicing surgeons. Summary Choledochoscopy is effective in reducing the incidence of retained biliary stones and for the removal
376
of retained calculi through the T-tube tract. It has also been of value in performing complex reconstructive and diversionary procedures on the common duct. Knowledge of the biliary anatomy is a prerequisite for the development of skill in choledochoscopy. The use of a biliary endoscopy teaching model with stones has been very effective in teaching the techniques of biliary endoscopy. Experience with the choledochoscope and its accessories should precede its use for postoperative choledochoscopy. References 1. Burhenne HJ. Nonoperative retained biliary stone extraction: a new roentgenologic technique. AJR 1973;117:388-90. 2. Mazzarello Ft. Review of 220 cases of residual biliary tract calculi treated without reoperation: an eight-year study. Surgery 1973;73:299-306. 3. Moss JP, Whelan JG, Powell RW, Dedman TC, Oliver WJ. Postoperative choledochoscopy via the T-tube tract. JAMA 1976;236:2781-2. 4. Whelan JG. Moss JP. Biliary tract exploration via T-tube tract: improved techniaue. AJR 1979:133:837-42. 5. Schetn CJ. Biliary endoscopy: an appraisal of its value in biliary lithiasis. Surgery 1969;65:1004-6. 6. Shore JM, Berci G, Morgenstern L. The value of biliary endoscopy. Surg Gynecol Obstet 1975; 140:60 l-4. 7. Rattner DW, Warshaw AL. Impact of choledochoscopy on the management of choledocholithiasis. Ann Surg 1981; 194: 76-9. 8. King EG. A teaching model for bronchoscopy. Chest 1976;70: 72-3.
The American Journal of Surgery