Common Bile Duct Exploration (CBDE)
What the Examiner Expects
Surgical exploration of the common bile duct to remove choledocholithiasis, performed either at the time of cholecystectomy or as a separate procedure. The examiner expects you to know two approaches: transcystic (dilating the cystic duct and passing a choledochoscope or Fogarty balloon catheter through it to extract stones — best for small, few, distal CBD stones) and choledochotomy (longitudinal incision on the anterior CBD — for large, multiple, or proximal stones). After choledochotomy, the duct is closed primarily over a T-tube for decompression, or primarily without a T-tube if the CBD is dilated (> 8 mm). Completion choledochoscopy should confirm complete stone clearance.
Key Examiner Focus Points
- Indicated when CBD stones are found on intraop cholangiogram during cholecystectomy
- Transcystic approach (through cystic duct) for small, few, distal stones
- Choledochotomy (direct CBD incision) for large or multiple stones
- Close choledochotomy over a T-tube or primarily if CBD is > 8 mm
- Alternative: postoperative ERCP for stone extraction
Common Curveballs
Intraop cholangiogram shows a single 5 mm stone in the distal CBD
This can be managed transcystically: glucagon to relax the sphincter, flush with saline, or pass a Fogarty balloon. Alternatively, if the cystic duct is large enough, pass a choledochoscope transcystically. If these fail, perform a choledochotomy or plan postoperative ERCP.
You cannot pass the choledochoscope past a stricture in the distal CBD
A distal CBD stricture in the setting of stones may be a benign peptic stricture, but you must consider and rule out periampullary malignancy (cholangiocarcinoma, pancreatic head cancer, ampullary cancer). Biopsy if possible. If the procedure is elective, close and obtain MRCP/EUS postoperatively for further evaluation.
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