This video demonstrates the steps in performing a common bile duct exploration for gall stones, choledochoscopy and either primary closure or repair over a T-tube. How to do Safe Laparoscopic Choledocotomy - Lecture by Dr R K Mishra. In the era of laparoscopic surgery, treatment strategies for common bile duct stones remain controversial. Laparoscopic choledochotomy is usually indicated only when transcystic duct exploration is not feasible. However, laparoscopic choledochotomy provides complete access to the ductal system and has a higher clearance rate than the transcystic approach. In addition, primary closure of the choledochotomy with a running suture and absorbable clips facilitates the procedure. Therefore, to avoid postoperative biliary stenosis, all patients with bile duct stones can be indicated for choledochotomy, except for those with non dilated common bile duct. Placement of a C-tube also provides access for the clearance of possible retained stones by endoscopic sphincterotomy as a backup procedure.
 

How to do Safe Laparoscopic Choledocotomy – Lecture by Dr. R. K. Mishra at World Laparoscopy Hospital

Laparoscopic surgery has revolutionized the field of hepatobiliary surgery by providing safer procedures, faster recovery, and minimal postoperative pain. One of the most delicate procedures in minimally invasive surgery is laparoscopic choledocotomy, a technique used to remove stones from the common bile duct (CBD). In a comprehensive lecture at World Laparoscopy Hospital, renowned laparoscopic surgeon Dr. R. K. Mishra explained the step-by-step approach to performing a safe laparoscopic choledocotomy, emphasizing surgical precision, patient safety, and proper technique.

The lecture begins with an overview of the indications for choledocotomy. This procedure is usually performed in patients who have common bile duct stones (choledocholithiasis) that cannot be removed through endoscopic techniques or when laparoscopic exploration of the bile duct is required during gallbladder surgery. Dr. Mishra highlights that careful preoperative evaluation, including ultrasound, MRCP, or intraoperative cholangiography, is essential to confirm the presence and location of stones.

Patient positioning and port placement are critical steps for successful laparoscopic choledocotomy. According to Dr. Mishra, the patient is placed in a supine position with slight reverse Trendelenburg, which improves exposure of the hepatobiliary area. Standard laparoscopic ports similar to those used in laparoscopic cholecystectomy are inserted, with an additional working port when necessary. Proper ergonomics and triangulation of instruments help the surgeon maintain precise control during dissection.

The next step involves careful dissection of Calot’s triangle and identification of the cystic duct and common bile duct. Dr. Mishra stresses the importance of clear anatomical identification to avoid injury to surrounding structures such as the hepatic artery and bile ducts. Gentle dissection using atraumatic instruments helps expose the common bile duct safely.

Once the CBD is clearly identified, a small longitudinal incision is made on the anterior surface of the duct using a laparoscopic knife or hook cautery. This step, known as choledocotomy, must be performed with extreme caution to prevent damage to the duct wall. After the incision is made, stones are removed using specialized instruments such as Dormia baskets, graspers, or suction devices. In many cases, a choledochoscope is introduced to visualize the duct internally and ensure complete stone clearance.

Dr. Mishra emphasizes that complete exploration of the bile duct is essential before closure. Irrigation with saline and direct visualization using choledochoscopy help confirm that no residual stones remain. Failure to remove all stones may lead to postoperative complications and recurrence.

The closure of the choledocotomy incision is another crucial step. Depending on the clinical situation, the surgeon may choose primary closure with fine absorbable sutures or placement of a T-tube for drainage. Dr. Mishra explains that primary closure is increasingly preferred when the duct is healthy and stone clearance is complete, as it reduces postoperative discomfort and hospital stay.

Safety remains the central theme throughout the lecture. Dr. Mishra advises surgeons to maintain gentle tissue handling, clear visualization, and meticulous suturing techniques. He also highlights the importance of proper training and simulation before performing advanced laparoscopic procedures. Institutions like World Laparoscopy Hospital play a vital role in providing hands-on training and structured education to surgeons from around the world.

In conclusion, laparoscopic choledocotomy is a highly effective minimally invasive technique for managing common bile duct stones when performed with precision and expertise. Through his detailed lecture, Dr. R. K. Mishra demonstrates that a systematic approach, proper anatomical knowledge, and adherence to safety principles are key to achieving successful outcomes. The training and guidance offered at World Laparoscopy Hospital continue to equip surgeons with the advanced skills required to perform complex laparoscopic procedures safely and confidently.