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Case 36: Trouble getting a cholangiogram.

You have had difficulty dissecting laparoscopically a small contracted, chronically fibrosed gallbladder. You have now performed a cholangiogram and cannot get the contrast to flow proximally to show the intrahepatic ductal anatomy. Here is your cholangiogram.

1. What manoeuvres can you use to get the contrast to flow 'up-hill'?

1. Tilt the patient head down
2. Use more contrast
3. Gently apply pressure over the region of the lower CBD with the side of a grasper to increase resistance to flow.

2. You realise what the problem is at this stage. What does your cholangiogram show?

The cholangiogram demonstrates cannulation of the CBD and all contrast is flowing down and into the duodenum. This is evidenced by a tapering of the CBD by the Olsen-Reddich clamp with no proximal flow, and no apparent cystic duct.

3. What structure is marked '1'?

The pancreatic duct

4. What is happening at '2'?

Free flow of contrast into the duodenum



This case presents one of the arguments in favour of routine intraoperative cholangiography:

Imagine that the cholangiogram was not performed. The surgeon would have clipped and divided the common bile duct at this level, dissected superiorly behind the bile duct (falsely assuming that this was the gallbladder) and into the porta - only at this stage when confronting further ductal strictures would the surgeon be alerted to his mistake. The resulting biliary injury would potentially be much worse. Also associated hepatic vascular injury could confound the problem.




PubMed - Routine cholangiography reduces sequelae of common bile duct injuries.




Powerpoint Presentation
Management of Acute Bile Duct Injuries