Prevent CBD Injury
Prevention of Common Bile Duct Injury by Cystic Duct Marking
The concept is to mark the site of the planned clipping of The Cystic Duct.
Step 1: The (assumed) Cystic Duct is identified and dissected.
Step 2: It is marked by the placement of radio-opaque clips upon
a. The fibro-areolar tissue around the Cystic Duct
OR
b. Upon the Cystic Artery (Figure 1)
Step 3: Confirmation by Cholangiography
This cholangiography has to be other than the usual cystic duct cholangiography. Because if the common bile duct has been misidentified as the cystic duct and cystic duct cholangiography is attempted, the injury of the “mistaken ductotomy” of the common bile duct will result.
Fig 1: The Kumar Clamp® and Catheter.
Kumar Cholangiography* is Better:
(Figure 2)
- The Kumar Clamp® is a 5 mm grasper. It is applied through the right mid-subcostal port (in the conventional method) and is used as a grasper for traction at the infundibulum during dissection of the cystic duct.
- The cystic duct is then milked towards the gallbladder to eliminate stones/sludge.
- The Kumar Clamp® has long, atraumatic jaws. It is reapplied completely across the lower part of the body of the gallbladder. (Figure 2)
- The Kumar Catheter® is then advanced through the clamp channel. It carries a short 19 ga needle to puncture the Hartmann’s pouch of the gallbladder for biliary access and dye injection.
Fig 2
There is no cystic duct cannulation.
The injury from the mistaken ductotomy of the common bile duct is thus eliminated.
The Cholangiogram in Figure 3 shows clips (arrow) on the fibro-areolar tissue or Cystic Artery, lying adjacent to the planned site of clipping and cutting of the Cystic Duct. The cystic duct and the planned site of clipping have thus been confirmed.
The Cholangiogram in Figure 4 shows an impending transection of the Common Bile Duct. Clips (arrow) are located on a misidentified common bile duct.
Cystic duct marking and Kumar cholangiography* prevented a common duct injury in this patient.
Fig 3 & 4